What is Stilted Speech?


In psychiatry, stilted speech or pedantic speech is communication characterised by situationally-inappropriate formality (refer to Communication Deviance). This formality can be expressed both through abnormal prosody as well as speech content that is “inappropriately pompous, legalistic, philosophical, or quaint”. Often, such speech can act as evidence for autism spectrum disorder (ASD) or a thought disorder, a common symptom in schizophrenia or schizotypal personality disorder.

To diagnose stilted speech, researchers have previously looked for the following characteristics:

  • Speech conveying more information than necessary.
  • Vocabulary and grammar expected from formal writing rather than conversational speech.
  • Unneeded repetition or corrections.

While literal and long-winded word content is often the most identifiable feature of stilted speech, such speech often displays irregular prosody, especially in resonance. Often, the loudness, pitch, rate, and nasality of pedantic speech vary from normal speech, resulting in the perception of pedantic or stilted speaking. For example, overly loud or high-pitched speech can come across to listeners as overly forceful while slow or nasal speech creates an impression of condescension.

These attributions, which are commonly found in patients with ASD, partially account for why stilted speech has been considered a diagnostic criterion for the disorder. Stilted speech, along with atypical intonation, semantic drift, terseness, and perseveration, are all qualities known to be commonly impaired during conversation with adolescents on the autistic spectrum. Often, stilted speech found in children with ASD will also be especially stereotypic or rehearsed.

Patients with schizophrenia are also known to experience stilted speech. This symptom is attributed to both an inability to access more commonly used words and a difficulty understanding pragmatics – the relationship between language and context. However, stilted speech appears as a less common symptom compared to a certain number of other symptoms of the psychosis. This element of cognitive disorder is also exhibited as a symptom in the narcissistic personality disorder.

There is disagreement on the definition of psychophenomenology within the discipline of psychiatry, e.g. published sources provide definitions that are “various and sometimes conflicting (Rule 2005)”.

What is Communication Deviance?


Communication deviance (CD) occurs when a speaker fails to effectively communicate meaning to their listener with confusing speech patterns or illogical patterns.

Refer to Stilted Speech.


These disturbances can range from vague linguistic references, contradictory statements to more encompassing non-verbal problems at the level of turn-taking.

The term was originally introduced by Lyman Wynne and Margaret Singer in 1963 to describe a communication style found among parents who had children with schizophrenia. According to Wynne, people are able to focus their attention and identify meaning from external stimuli beginning with their interactions, particularly with their parents, during their early years of life. In family communication, deviance is present in the way members acknowledge or affirm one another as well as in task performance.

A recent meta-analysis reported that communication deviance is highly prevalent in parents of patients diagnosed with schizophrenia and adoption studies have reported significant associations between CD in the parent and thought disorder in the offspring, however, the mechanisms by which CD impacts on the offspring’s cognition are still unknown. Some researchers theorize that, in the case of a high degree of egocentric communication in parents where the sender and the receiver do not speak and listen according to each other’s premises, the child develops uncertainty.

The research of psychiatrists and psychoanalysts Lyman Wynne and Theodore Lidz on communication deviance and roles (e.g. pseudo-mutuality, pseudo-hostility, schism and skew) in families of people with schizophrenia also became influential with systems-communications-oriented theorists and therapists.

What is Active Listening?


Active listening is a technique of careful listening and observation of non-verbal cues, with feedback in the form of accurate paraphrasing, that is used in counselling, training, and solving disputes or conflicts.

It requires the listener to pay attention, understand, respond and remember what is being said in the context of intonation, timing, and non-verbal cues (body language). This differs from other listening techniques like reflective listening and empathic listening.

Reflective listening is a communication strategy involving seeking to understand a speaker’s idea, then offering the idea back to the speaker, to confirm the idea has been understood correctly. Empathic listening is about giving people an outlet for their emotions before being able to be more open, sharing experiences and being able to accept new perspectives on troubled topics that cause emotional suffering. Listening skills may establish flow rather than closed mindedness.

Brief History

Carl Rogers and Richard Farson coined the term “active listening” in 1957 in a paper of the same title (reprinted in 1987 in the volume “Communicating in Business Today”). Practicing active listening also emphasized Rogers’ (1980) concept of three facilitative conditions for effective counselling; empathy, genuineness, and unconditional positive regard. Rogers and Farson write: “Active listening is an important way to bring about changes in people. Despite the popular notion that listening is a passive approach, clinical and research evidence clearly shows that sensitive listening is a most effective agent for individual personality change and group development. Listening brings about changes in peoples’ attitudes toward themselves and others; it also brings about changes in their basic values and personal philosophy. People who have been listened to in this new and special way become more emotionally mature, more open to their experiences, less defensive, more democratic, and less authoritarian.”


Active listening comprises several components by the listener, who must pay attention to what the speaker is attempting to communicate and elicit clarification where necessary for comprehension.

Active listening involves the listener observing the speaker’s non-verbal behaviour and body language. The listener can observe non-verbal behaviours through kinesics, the study of body motion and posture; paralinguistics, the study of the tone of words; and proxemics, the study of physical distance and posture between speakers. Having the ability to interpret a person’s body language lets the listener develop a more accurate understanding of the speaker’s message.


Comprehension is a shared meaning between parties in a communication transaction. This is the first step in the listening process. The second step is being able to take breaks between discernible words, or talking segmentation.


Retaining is the second step in the process. Memory is essential to the active listening process because the information retained when a person is involved in the listening process is how meaning is extracted from words. Because everyone has different memories, the speaker and the listener may attach different meanings to the same statement. Memories are fallible, things like cramming may cause information to be forgotten.


Active listening is an interaction between speaker and listener. It adds action to a normally passive process.


Active listening can be assessed using the active listening observation scale (ALOS).


The Active Listening Observation Scale (ALOS) was developed to measure the perceived or observed frequency of active listening enacted by physicians during patient consultations. Fassaert, van Dulmen, Schellevis, & Bensing (2007) provided evidence of adequate reliability estimates (α > .80) and construct validity for a 7-item version of the ALOS. Additional research has extended the ALOS to supportive listening contexts and provided evidence of appropriate reliability with 11 items (α > .90) as well as evidence of measurement model validity (Bodie & Jones, 2012). As of 2017, researchers are currently developing an extensive validity portfolio for the scale, particularly as an assessment of the occurrence of particular behaviours associated with active listening such as asking questions and displaying nonverbal understanding.

Other scales include:

  • Facilitating Listening Scale (FLS).
  • Active – Empathic Listening Scale (AELS).
  • Active Listening Attitude Scale (ALAS).

Refer to The Sourcebook of Listening Research: Methodology and Measures (25 August 2017) by Debra L. Worthington and Graham D. Bodie (Editors), published by John Wiley & Sons Inc.

Barriers to Active Listening

There are a multitude of factors that may impede upon someone’s ability to listen with purpose and intention; these factors are referred to as listening blocks. Some examples of these blocks include rehearsing, filtering, and advising. Rehearsing is when the listener is more focused on preparing their response rather than listening. Filtering is when a listener focuses only on what they expect to hear, while tuning out other aspects of what is being said, and lastly, advising is when the listener focuses on problem solving, which can create a sense of pressure to fix what the other person is doing wrong. Some barriers are due to hunger or fatigue of the listener, making them irritated and less inclined to listen to the speaker. Sometimes it is due to the language the speaker uses – such as high sounding and bombastic words that can lead to ambiguity. Other barriers include distractions, trigger words, vocabulary, and limited attention span.

Individuals in conflict often contradict each other. Ambushing occurs when one listens to someone else’s argument for its weaknesses and ignore its strengths. This may include a distortion of the speaker’s argument to gain a competitive advantage. On the other hand, if one finds that the other party understands, an atmosphere of cooperation can be created.

Shift Response

Shift response is the general tendency of a speaker in a conversation to affix attention to their position.[citation needed] This is a type of conversational narcissism – the tendency of listeners to turn the topic to themselves without showing sustained interest in others. A support response is the opposite of a shift response; it is an attention giving method and a cooperative effort to focus the conversational attention on the other person. Instead of being me-oriented like shift response, it is we-oriented. It is the response a competent communicator is most likely to use.

Understanding of Non-Verbal Cues

Ineffective listeners are unaware of non-verbal cues, though they dramatically affect how people listen. To a certain extent, it is also a perceptual barrier. Up to 93% of people’s attitudes are formed by non-verbal cues. This should help one to avoid undue influence from non-verbal communication. In most cases, the listener does not understand the non-verbal cues the speaker uses. A person may show fingers to emphasize a point, but this may be perceived as an intent by the speaker to place their fingers in the listener’s eyes. Overuse of non-verbal cues also creates distortion, and as a result listeners may be confused and forget the correct meaning.

Overcoming Listening Barriers

The active listening technique is used to improve personal communications in organizations. Listeners put aside their own emotions and ask questions and paraphrase what the speaker says to clarify and gain a better understanding of what the speaker intended to say. Distractions that interrupt the listener’s attention are one of the major barriers to effective listening. These include external factors such as background noise and physical discomfort, and internal distractions, such as thoughts about other things and lack of focus. Another barrier is misinterpretation of what the speaker is attempting to communicate, including assumption of motives, and “reading between the lines”, as is premature judgment of the speaker’s point, which can occur as a consequence of the listener holding onto a rigid personal opinion on the topic. This problem can be mitigated by asking the speaker what they mean when it is unclear, though this is not guaranteed to work every time. A strong disagreement hinders the ability to listen closely to what is being said. Eye contact and appropriate body languages are seen as important components to active listening, as they provide feedback to the speaker. The stress and intonation used by the speaker may also provide information to the listener, which is not available in the written word.


Active listening is used in a wide variety of situations, including public interest advocacy, community organising, tutoring, medical workers talking to patients, HIV counselling, helping suicidal persons, management, counselling and journalistic settings. In groups it may aid in reaching consensus. It may also be used in casual conversation or small talk to build understanding, though this can be interpreted as condescending.

A listener can use several degrees of active listening, each resulting in a different quality of communication.

The proper use of active listening results in getting people to open up, avoiding misunderstandings, resolving conflict, and building trust. In a medical context, benefits may include increased patient satisfaction, improved cross-cultural communication, improved outcomes, or decreased litigation.

Active Listening in Music

Active listening has been developed as a concept in music and technology by François Pachet, researcher at Sony Computer Science Laboratory, Paris. Active listening in music refers to the idea that listeners can be given some degree of control on the music they listen to, by means of technological applications mainly based on artificial intelligence and information theory techniques, by opposition to traditional listening, in which the musical media is played passively by some neutral device.


A Munich-based marital therapy study conducted by Dr. Kurt Hahlweg and associates found that even after employing active listening techniques in the context of couple’s therapy, the typical couple was still distressed.

Active listening was criticized by John Gottman’s The Seven Principles for Making Marriage Work as being of limited usefulness:

Active listening asks couples to perform Olympic-level emotional gymnastics when their relationship can barely walk. . . . After studying some 650 couples and tracking the fate of their marriages for up to fourteen years, we now understand that this approach to counseling doesn’t work, not just because it’s nearly impossible for most couples to do well, but more importantly because successful conflict resolution isn’t what makes marriages succeed. One of the most startling findings of our research is that most couples who have maintained happy marriages rarely do anything that even partly resembles active listening when they’re upset.

Robert F. Scuka defends active listening by arguing that:

…a careful reading of the Hahlweg et al. (1984) study reveals that Gottman cites only certain (one-sided) results from the study. He also overlooks several important considerations that call into question his implied dismissal of the RE model as a legitimate therapeutic intervention for distressed couples.

Book: Communication and Mental Health Disorders: Developing Theory, Growing Practice

Book Title:

Communication and Mental Health Disorders: Developing Theory, Growing Practice.

Author(s): Caroline Jagoe and Irene P. Walsh (Editor).

Year: 2019.

Edition: First (1st).

Publisher: J & R Press Ltd.

Type(s): Paperback.


Communication and Mental Health Disorders: Developing Theory, Growing Practice brings together academics and expert clinicians to share their research, clinical expertise and insights in the presentation of current theory and evolving practice of language and communication work with children and adults with mental health disorders. The book presents recent developments in the field against a background of ‘recovery model’ principles and practices, moving beyond introductory texts published previously.

This book is a highly comprehensive text drawing on multidisciplinary perspectives in the care of people with communication difficulties and mental health disorders. It covers a broad range of areas, providing an extensive exploration of the unique and complex relationship between mental health and disorder, and language and communication, with specific emphasis on the application of theoretical developments to clinical practice. The focus is on recent and cutting-edge developments in the field, whilst acknowledging historical constructs and contexts. Service users’ perceptions are incorporated throughout alongside those of mental healthcare professionals (e.g., psychiatrists and speech and language therapists). A full section on advances in approaches to communication intervention presents the strides taken in the practical applications of innovative thinking in the area.

What is a Double Bind?


A double bind is a dilemma in communication in which an individual (or group) receives two or more conflicting messages, with one negating the other. In some circumstances (particularly families and relationships) this might be emotionally distressing. This creates a situation in which a successful response to one message results in a failed response to the other (and vice versa), so that the person will automatically be wrong regardless of response. The double bind occurs when the person cannot confront the inherent dilemma, and therefore can neither resolve it nor opt out of the situation.

Double bind theory was first described by Gregory Bateson and his colleagues in the 1950s.

Double binds are often utilised as a form of control without open coercion – the use of confusion makes them difficult both to respond to and to resist.

A double bind generally includes different levels of abstraction in the order of messages and these messages can either be stated explicitly or implicitly within the context of the situation, or they can be conveyed by tone of voice or body language. Further complications arise when frequent double binds are part of an ongoing relationship to which the person or group is committed.

Refer to Family Therapy and the Bateson Project (1953-1963).


The double bind is often misunderstood to be a simple contradictory situation, where the subject is trapped by two conflicting demands. While it is true that the core of the double bind is two conflicting demands, the difference lies in how they are imposed upon the subject, what the subject’s understanding of the situation is, and who (or what) imposes these demands upon the subject. Unlike the usual no-win situation, the subject has difficulty in defining the exact nature of the paradoxical situation in which they are caught. The contradiction may be unexpressed in its immediate context and therefore invisible to external observers, only becoming evident when a prior communication is considered. Typically, a demand is imposed upon the subject by someone whom they respect (such as a parent, teacher, or doctor) but the demand itself is inherently impossible to fulfil because some broader context forbids it. For example, this situation arises when a person in a position of authority imposes two contradictory conditions but there exists an unspoken rule that one must never question authority.

Gregory Bateson and his colleagues defined the double bind as follows:

  1. The situation involves two or more people, one of whom (for the purpose of the definition), is designated as the “subject”. The others are people who are considered the subject’s superiors: figures of authority (such as parents), whom the subject respects.
  2. Repeated experience: the double bind is a recurrent theme in the experience of the subject, and as such, cannot be resolved as a single traumatic experience.
  3. A ‘primary injunction’ is imposed on the subject by the others generally in one of two forms:
    • (a) “Do X, or I will punish you”; or
    • (b) “Do not do X, or I will punish you.”
    • The punishment may include the withdrawing of love, the expression of hate and anger, or abandonment resulting from the authority figure’s expression of helplessness.
  4. A ‘secondary injunction’ is imposed on the subject, conflicting with the first at a higher and more abstract level. For example: “You must do X, but only do it because you want to.” It is unnecessary for this injunction to be expressed verbally.
  5. If necessary, a ‘tertiary injunction’ is imposed on the subject to prevent them from escaping the dilemma.
    • See phrase examples below for clarification.
  6. Finally, Bateson states that the complete list of the previous requirements may be unnecessary, in the event that the subject is already viewing their world in double bind patterns. Bateson goes on to give the general characteristics of such a relationship:
    • When the subject is involved in an intense relationship; that is, a relationship in which he feels it is vitally important that he discriminate accurately what sort of message is being communicated so that he may respond appropriately;
    • And, the subject is caught in a situation in which the other person in the relationship is expressing two orders of message and one of these denies the other;
    • And, the subject is unable to comment on the messages being expressed to correct his discrimination of what order of message to respond to: i.e., he cannot make a metacommunicative statement.

Thus, the essence of a double bind is two conflicting demands, each on a different logical level, neither of which can be ignored or escaped. This leaves the subject torn both ways, so that whichever demand they try to meet, the other demand cannot be met. “I must do it, but I can’t do it” is a typical description of the double-bind experience.

For a double bind to be effective, the subject must be unable to confront or resolve the conflict between the demand placed by the primary injunction and that of the secondary injunction. In this sense, the double bind differentiates itself from a simple contradiction to a more inexpressible internal conflict, where the subject really wants to meet the demands of the primary injunction, but fails each time through an inability to address the situation’s incompatibility with the demands of the secondary injunction. Thus, subjects may express feelings of extreme anxiety in such a situation, as they attempt to fulfil the demands of the primary injunction albeit with obvious contradictions in their actions.

This was a problem in United States legal circles prior to the Fifth Amendment to the United States Constitution being applied to state action. A person could be subpoenaed to testify in a federal case and given Fifth Amendment immunity for testimony in that case. However, since the immunity did not apply to a state prosecution, the person could refuse to testify at the Federal level despite being given immunity, thus subjecting the person to imprisonment for contempt of court, or the person could testify, and the information they were forced to give in the Federal proceeding could then be used to convict the person in a state proceeding.

Brief History

The term double bind was first used by the anthropologist Gregory Bateson and his colleagues (including Don D. Jackson, Jay Haley and John H. Weakland) in the mid-1950s in their discussions on complexity of communication in relation to schizophrenia. Bateson made clear that such complexities are common in normal circumstances, especially in “play, humour, poetry, ritual and fiction” (see Logical Types below). Their findings indicated that the tangles in communication often diagnosed as schizophrenia are not necessarily the result of an organic brain dysfunction. Instead, they found that destructive double binds were a frequent pattern of communication among families of patients, and they proposed that growing up amidst perpetual double binds could lead to learned patterns of confusion in thinking and communication.

Complexity in Communication

Human communication is complex, and context is an essential part of it. Communication consists of the words said, tone of voice, and body language. It also includes how these relate to what has been said in the past; what is not said, but is implied; how these are modified by other nonverbal cues, such as the environment in which it is said, and so forth. For example, if someone says “I love you”, one takes into account who is saying it, their tone of voice and body language, and the context in which it is said. It may be a declaration of passion or a serene reaffirmation, insincere and/or manipulative, an implied demand for a response, a joke, its public or private context may affect its meaning, and so forth.

Conflicts in communication are common and often we ask “What do you mean?” or seek clarification in other ways. This is called meta-communication: communication about the communication. Sometimes, asking for clarification is impossible. Communication difficulties in ordinary life often occur when meta-communication and feedback systems are lacking or inadequate or there is not enough time for clarification.

Double binds can be extremely stressful and become destructive when one is trapped in a dilemma and punished for finding a way out. But making the effort to find the way out of the trap can lead to emotional growth.


The classic example given of a negative double bind is of a mother telling her child that she loves them, while at the same time turning away in disgust, or inflicting corporal punishment as discipline: the words are socially acceptable; the body language is in conflict with it. The child does not know how to respond to the conflict between the words and the body language and, because the child is dependent on the mother for basic needs, they are in a quandary. Small children have difficulty articulating contradictions verbally and can neither ignore them nor leave the relationship.

Another example is when one is commanded to “be spontaneous”. The very command contradicts spontaneity, but it only becomes a double bind when one can neither ignore the command nor comment on the contradiction. Often, the contradiction in communication is not apparent to bystanders unfamiliar with previous communications.

Phrase Examples

  • An example from Gerald M. Weinberg in a non-family situation…. “I suggest you find someone who you feel is more capable in this role”.
    • This requires the recipient to either confirm that the current incumbent in the role is sufficiently capable, or accept that they choose someone else based on their feelings – not an objective assessment of whether the incumbent is capable.
  • Mother telling her child: “You must love me”.
  • The primary injunction here is the command itself: “you must”; the secondary injunction is the unspoken reality that love is spontaneous, that for the child to love the mother genuinely, it can only be of their own accord.
  • Child-abuser to child: “You should have escaped from me earlier, now it’s too late—because now, nobody will believe that you didn’t want what I have done”, while at the same time blocking all of the child’s attempts to escape.
  • Child-abusers often start the double-bind relationship by “grooming” the child, giving little concessions, or gifts or privileges to them, thus the primary injunction is: “You should like what you are getting from me!”
  • When the child begins to go along (i.e. begins to like what they are receiving from the person), then the interaction goes to the next level and small victimisation occurs, with the secondary injunction being: “I am punishing you! (for whatever reason the child-abuser is coming up with, e.g. “because you were bad/naughty/messy”, or “because you deserve it”, or “because you made me do it”, etc.).
  • If child shows any resistance (or tries to escape) from the abuser, then the words: “You should have escaped from me earlier (…)” serve as the third level or tertiary injunction.
  • Then the loop starts to feed on itself, allowing for ever worse victimisation to occur.
  • Mother to son: “Leave your sister alone!”, while the son knows his sister will approach and antagonize him to get him into trouble.
  • The primary injunction is the command, which he will be punished for breaking.
    • The secondary injunction is the knowledge that his sister will get into conflict with him, but his mother will not know the difference and will default to punishing him.
    • He may be under the impression that if he argues with his mother, he may be punished.
    • One possibility for the son to escape this double bind is to realise that his sister only antagonises him to make him feel anxious (if indeed it is the reason behind his sister’s behaviour).
  • If he were not bothered about punishment, his sister might not bother him.
    • He could also leave the situation entirely, avoiding both the mother and the sister.
    • The sister can not claim to be bothered by a non-present brother, and the mother can not punish (or scapegoat) a non-present son.
    • Other solutions exist too, which are based on the creative application of logic and reasoning.
  • An apt reply would be: “Please tell sis the same”. If mother wants to ‘scapegoat’ him, her response will be negative.
    • The command has a negative undertone towards the son.

Positive Double Binds

Bateson also described positive double binds, both in relation to Zen Buddhism with its path of spiritual growth, and the use of therapeutic double binds by psychiatrists to confront their patients with the contradictions in their life in such a way that would help them heal. One of Bateson’s consultants, Milton H. Erickson (5 volumes, edited by Rossi) eloquently demonstrated the productive possibilities of double binds through his own life, showing the technique in a brighter light.

The Science

One of the causes of double binds is the loss of feedback systems. Gregory Bateson and Lawrence S. Bale describe double binds that have arisen in science that have caused decades-long delays of progress in science because the scientific community had defined something as outside of its scope (or as “not science”) – see Bateson in his Introduction to Steps to an Ecology of Mind (1972, 2000), pp.xv–xxvi; and Bale in his article, Gregory Bateson, Cybernetics and the Social/Behavioural Sciences (esp. pp.1-8) on the paradigm of classical science vs. that of systems theory/cybernetics. (See also Bateson’s description in his Forward of how the double bind hypothesis fell into place).

Work by Bateson


The Double Bind Theory was first articulated in relationship to schizophrenia, but Bateson and his colleagues hypothesized that schizophrenic thinking was not necessarily an inborn mental disorder but a learned confusion in thinking.

It is helpful to remember the context in which these ideas were developed. Bateson and his colleagues were working in the Veteran’s Administration Hospital (1949-1962) with World War II veterans. As soldiers they’d been able to function well in combat, but the effects of life-threatening stress had affected them. At that time, 18 years before Post-Traumatic Stress Disorder was officially recognised, the veterans had been saddled with the catch-all diagnosis of schizophrenia. Bateson did not challenge the diagnosis but he did maintain that the seeming nonsense the patients said at times did make sense within context, and he gives numerous examples in section III of Steps to an Ecology of Mind, “Pathology in Relationship”. For example, a patient misses an appointment, and when Bateson finds him later the patient says ‘the judge disapproves’; Bateson responds, “You need a defense lawyer”. Bateson also surmised that people habitually caught in double binds in childhood would have greater problems – that in the case of the schizophrenic, the double bind is presented continually and habitually within the family context from infancy on. By the time the child is old enough to have identified the double bind situation, it has already been internalised, and the child is unable to confront it. The solution then is to create an escape from the conflicting logical demands of the double bind, in the world of the delusional system.

One solution to a double bind is to place the problem in a larger context, a state Bateson identified as Learning III, a step up from Learning II (which requires only learned responses to reward/consequence situations). In Learning III, the double bind is contextualized and understood as an impossible no-win scenario so that ways around it can be found.

Bateson’s double bind theory was never followed up by research into whether family systems imposing systematic double binds might be a cause of schizophrenia. This complex theory has been only partly tested, and there are gaps in the current psychological and experimental evidence required to establish causation. The current understanding of schizophrenia emphasizes the robust scientific evidence for a genetic predisposition to the disorder, with psychosocial stressors, including dysfunctional family interaction patterns, as secondary causative factors in some instances.


After many years of research into schizophrenia, Bateson continued to explore problems of communication and learning, first with dolphins, and then with the more abstract processes of evolution. Bateson emphasised that any communicative system characterized by different logical levels might be subject to double bind problems. Especially including the communication of characteristics from one generation to another (genetics and evolution).

“…evolution always followed the pathways of viability. As Lewis Carroll has pointed out, the theory [of natural selection] explains quite satisfactorily why there are no bread-and-butter-flies today.”

Bateson used the fictional Bread and Butter Fly (from Through the Looking Glass, and What Alice Found There) to illustrate the double bind in terms of natural selection. The gnat points out that the insect would be doomed if he found his food (which would dissolve his own head, since this insect’s head is made of sugar, and his only food is tea), and starve if he did not. Alice suggests that this must happen quite often, to which the gnat replies: “It always happens.”

The pressures that drive evolution therefore represent a genuine double bind. And there is truly no escape: “It always happens.” No species can escape natural selection, including our own.

Bateson suggested that all evolution is driven by the double bind, whenever circumstances change: If any environment becomes toxic to any species, that species will die out unless it transforms into another species, in which case, the species becomes extinct anyway.

Most significant here is Bateson’s exploration of what he later came to call ‘the pattern that connects’ – that problems of communication which span more than one level (e.g. the relationship between the individual and the family) should also be expected to be found spanning other pairs of levels in the hierarchy (e.g. the relationship between the genotype and the phenotype):

“We are very far, then, from being able to pose specific questions for the geneticist; but I believe that the wider implications of what I have been saying modify somewhat the philosophy of genetics. Our approach to the problems of schizophrenia by way of a theory of levels or logical types has disclosed first that the problems of adaptation and learning and their pathologies must be considered in terms of a hierarchic system in which stochastic change occurs at the boundary points between the segments of the hierarchy. We have considered three such regions of stochastic change—the level of genetic mutation, the level of learning, and the level of change in family organization. We have disclosed the possibility of a relationship of these levels which orthodox genetics would deny, and we have disclosed that at least in human societies the evolutionary system consists not merely in the selective survival of those persons who happen to select appropriate environments but also in the modification of family environment in a direction which might enhance the phenotypic and genotypic characteristics of the individual members.”

Girard’s Mimetic Double Bind

René Girard, in his literary theory of mimetic desire, proposes what he calls a “model-obstacle”, a role model who demonstrates an object of desire and yet, in possessing that object, becomes a rival who obstructs fulfilment of the desire. According to Girard, the “internal mediation” of this mimetic dynamic “operates along the same lines as what Gregory Bateson called the ‘double bind’.” Girard found in Sigmund Freud’s psychoanalytic theory, a precursor to mimetic desire. “The individual who ‘adjusts’ has managed to relegate the two contradictory injunctions of the double bind—to imitate and not to imitate—to two different domains of application. This is, he divides reality in such a way as to neutralize the double bind.” While critical of Freud’s doctrine of the unconscious mind, Girard sees the ancient Greek tragedy, Oedipus Rex, and key elements of Freud’s Oedipus complex, patricidal and incestuous desire, to serve as prototypes for his own analysis of the mimetic double bind.

Far from being restricted to a limited number of pathological cases, as American theoreticians suggest, the double bind – a contradictory double imperative, or rather a whole network of contradictory imperatives – is an extremely common phenomenon. In fact, it is so common that it might be said to form the basis of all human relationships.

Bateson is undoubtedly correct in believing that the effects of the double bind on the child are particularly devastating. All the grown-up voices around him, beginning with those of the father and mother (voices which, in our society at least, speak for the culture with the force of established authority) exclaim in a variety of accents, “Imitate us!” “Imitate me!” “I bear the secret of life, of true being!” The more attentive the child is to these seductive words, and the more earnestly he responds to the suggestions emanating from all sides, the more devastating will be the eventual conflicts. The child possesses no perspective that will allow him to see things as they are. He has no basis for reasoned judgements, no means of foreseeing the metamorphosis of his model into a rival. This model’s opposition reverberates in his mind like a terrible condemnation; he can only regard it as an act of excommunication. The future orientation of his desires – that is, the choice of his future models – will be significantly affected by the dichotomies of his childhood. In fact, these models will determine the shape of his personality.

If desire is allowed its own bent, its mimetic nature will almost always lead it into a double bind. The unchanneled mimetic impulse hurls itself blindly against the obstacle of a conflicting desire. It invites its own rebuffs and these rebuffs will in turn strengthen the mimetic inclination. We have, then, a self-perpetuating process, constantly increasing in simplicity and fervor. Whenever the disciple borrows from his model what he believes to be the “true” object, he tries to possess that truth by desiring precisely what this model desires. Whenever he sees himself closest to the supreme goal, he comes into violent conflict with a rival. By a mental shortcut that is both eminently logical and self-defeating, he convinces himself that the violence itself is the most distinctive attribute of this supreme goal! Ever afterward, violence will invariably awaken desire… (René Girard, Violence and the Sacred: “From Mimetic Desire to the Monstrous Double”, pp.156-157).

Neuro-Linguistic Programming

The field of Neuro-Linguistic Programming (NLP) also makes use of the expression “double bind”. Grinder and Bandler (both of whom had personal contact with Bateson and Erickson) asserted that a message could be constructed with multiple messages, whereby the recipient of the message is given the impression of choice – although both options have the same outcome at a higher level of intention. This is called a “double bind” in NLP terminology, and has applications in both sales and therapy. In therapy, the practitioner may seek to challenge destructive double binds that limit the client in some way and may also construct double binds in which both options have therapeutic consequences. In a sales context, the speaker may give the respondent the illusion of choice between two possibilities. For example, a salesperson might ask: “Would you like to pay cash or by credit card?”, with both outcomes presupposing that the person will make the purchase; whereas the third option (that of not buying) is intentionally excluded from the spoken choices.

Note that in the NLP context, the use of the phrase “double bind” does not carry the primary definition of two conflicting messages; it is about creating a false sense of choice which ultimately binds to the intended outcome. In the “cash or credit card?” example, this is not a “Bateson double bind” since there is no contradiction, although it still is an “NLP double bind”. Similarly if a salesman were selling a book about the evils of commerce, it could perhaps be a “Bateson double bind” if the buyer happened to believe that commerce was evil, yet felt compelled or obliged to buy the book.

Book: Pharmacotherapy Casebook – A Patient-Focused Approach

Book Title:

Pharmacotherapy Casebook – A Patient-Focused Approach.

Author(s): Terry Schwinghammer. Julia Koehler, Jill Borchert, Douglas Slain, and Sharon Park.

Year: 2020.

Edition: Eleventh (11ed).

Publisher: McGraw-Hill Education.

Type(s): Paperback and Kindle.


Packed with 157 patient cases, Pharmacotherapy Casebook: A Patient-Focused Approach builds your problem-solving and decision-making skills, so you can identify and resolve the most common drug therapy challenges you will encounter in daily practice.

Its case-based approach is also ideal for PharmD, Nurse Practitioner, and other allied health courses. Providing a consistent, practical approach, this authoritative guide delivers everything you need to master patient communication, care plan development, and documenting interventions. Case chapters are organised into system sections that correspond to those of the companion textbook.

Sharpen your ability to:

  • Identify actual or potential drug therapy problems.
  • Determine the desired therapeutic outcome.
  • Evaluate therapeutic alternatives.
  • Design an optimal individualised pharmacotherapeutic plan.
  • Evaluate the therapeutic outcome
  • Provide patient education.
  • Communicate and implement the therapeutic plan.

Develop expertise in pharmacotherapy decision making with:

  • Realistic patient presentations that include medial history, physical examination, and laboratory data, followed by a series of questions using a systematic, problem-solving approach
  • A broad range of cases – from a single disease state to multiple disease states and drug-related problems
  • Expert coverage that integrates the biomedical and pharmaceutical sciences with therapeutics
  • Appendices containing sample answer to several cases and valuable information on medical abbreviations, laboratory tests, mathematical conversion factors, and anthropometrics

What are the Historical Contexts to Communicating Mental Health?

Research Paper Title

Introduction: historical contexts to communicating mental health.


Contemporary discussions around language, stigma and care in mental health, the messages these elements transmit, and the means through which they have been conveyed, have a long and deep lineage.

Recognition and exploration of this lineage can inform how we communicate about mental health going forward, as reflected by the 9 papers which make up this special issue.

The researchers introduction provides some framework for the history of communicating mental health over the past 300 years. They show that there have been diverse ways and means of describing, disseminating and discussing mental health, in relation both to therapeutic practices and between practitioners, patients and the public. Communicating about mental health, they argue, has been informed by the desire for positive change, as much as by developments in reporting, legislation and technology.

However, while the modes of communication have developed, the issues involved remain essentially the same. Most practitioners have sought to understand and to innovate, though not always with positive results. Some lost sight of patients as people; patients have felt and have been ignored or silenced by doctors and carers. Money has always talked, for without adequate investment services and care have suffered, contributing to the stigma surrounding mental illness.

While it is certainly ‘time to talk’ to improve experiences, it is also time to change the language that underpins cultural attitudes towards mental illness, time to listen to people with mental health issues and, crucially, time to hear.


Wynter, R. & Smith, L. (2017) Introduction: historical contexts to communicating mental health. Medical Humanities. 43(2), pp.73-80. doi: 10.1136/medhum-2016-011082.

Overcoming Communication Difficulties

Communicating with People from Different Cultures

Any successful communication recognises the uniqueness of every culture, every relationship, and every individual – including you.

Some forms of verbal and non-verbal communication are appropriate and others are not appropriate. For instance, some individuals may regard prolonged eye contact as rude. We all have different ways of communicating our fears and needs when we become unwell. Invite the person to tell you about their life experiences, values, and belief systems. Also, ask them how they feel about asking for care and support.

Establish what is realistic for the individual, as well as what is culturally acceptable. Some cultures encourage the use of silence, whereas in others it creates embarrassment or awkwardness. In the French, Spanish, and Eastern European cultures, the presence of silence is a sign of agreement.

Working with an Interpreter or a Bilingual Worker

When an individual does not speak English at all, has limited English, or chooses to communicate their distress in their mother tongue, the best solution is to use a professional interpreter. The choice to use a trained interpreter or a family member must be made by the individual who is experiencing problems. Being able to do so will help the individual to fell that they are in control of the situation.

Language holds and creates the individual’s reality, experience, culture, and world view. A good interpreter will concentrate on accurately conveying equivalent meaning as well as reporting the direct answers to your questions and other responses offered. You should also be aware that the interpreter may bring their own bias to the situation.

Working with a British Sign Language Interpreter for the Deaf

There are very few services available for deaf people with mental health problems, although recently some deaf workers have been trained in mental health first aid.

If no deaf mental health first-aider is available, you may need to use an interpreter. In this case, you should take care to always face the deaf person when speaking and respond as though it is the deaf person speaking to you when the interpreter speaks. Remember that the interpreter is being the deaf person’s voice. Maintain good eye contact and show your feelings through your facial expressions. Deaf people do much of their communication through body language and facial expression, and are therefore skilled at reading feelings.

If no interpreter is available, you can still offer support and concern by showing your willingness to communicate. Deaf people can often lip read and can vocalise using English. Be patient and try hard to understand. Show your concern as you would with anyone in distress and ask the person who you can call for help.

Important Note

If you need to use a pen and paper to ask the person who they would like you to call for help or support, use very simple English.

British Sign Language is a different language to English – a person who was born deaf may not have English as their first language.

Tolerance is…

“Tolerance is a strange but indispensable civic virtue. It requires people to accept and live calmly with individuals and practices of which they disapprove.

Some take it for spineless laxity in the face of what ought to be fought or forbidden.

Others see it as a demeaning fraud that spares prohibition but withholds approval.

The tolerant themselves are not immune to its tricks and subtleties.

It takes little for them to shout intolerantly at each other about how far toleration should go.

Defending toleration is not like protecting a jewel. It takes fixity of aim but also a feel for the changing context, persistence with a task that never ends and readiness to start again.

Toleration does gradually spread. It can also suddenly vanish.” (The Economist, 2019, p.76).


The Economist. (2019) Intellectual History: Live and Let Live. The Economist. 18 May 2019, pp.76.