Something for Your Entire Family

Foundations of Family Therapy is a fascinating encyclopedia of the history, schools, techniques, and masters of family therapy. During the past thirty years, family therapy has expanded into an organized and rigorous discipline within the larger field of mental health. Its theoretical scheme and its practical techniques and training contrast with those of other mental health disciplines, such as psychiatry, social work, psychoanalysis, and supportive forms of family counseling. Family therapy may be described as a movement: family therapists believe that their picture of mental disturbance is more “true” to reality, superseding both traditional forms of therapy and contemporary therapies which center upon the individual client.

In her enthusiastic survey of the field, Hoffman both advances the movement of family therapy and establishes it as a serious intellectual discipline. According to Hoffman, family therapy is not just “a novel therapeutic technique” or even another theory of mental disturbance; it represents “a new epistemology,” which touches on all the sciences and replaces traditional theories of personal motivation. Unfortunately, these larger claims are sometimes grandiose and often inappropriate when addressed to a stereo-type of contemporary psychoanalysis (which here is labeled “the psychodynamic approach”).

“Epistemology”—the theory of knowledge—and “conceptual revolution” have become popular terms in psychotherapeutic writing. A theory of human behavior which purports to reveal the true nature of reality by way of the metaphor of knowing carries weight among therapists today. Another frequently used term, “scientific revolution,” which is borrowed from Thomas Kuhn, attempts to give a theory a progressive quality and, thus, protect it from charges of dogmatism.

But these concepts are part of two separate, and conflicting, belief systems. One holds that there is an absolute true reality which may be accurately represented by the correct method, the other that theoretical schemes are relative to a specific culture and time. In Hoffman’s book, the Kuhnian approach, which might help to restore a healthy relativism to the discipline of psychotherapy, is used to isolate, and thereby elevate, the author’s point of view. She offers us the true epistemology—a “circular,” “systemic” method—through which the real world which exists behind the mirror is, at last, made manifest. Indeed, in the first sentence, we are told that “this book is a journey to a newly discovered kingdom, the world behind the looking glass.” To Hoffman, the advent of the one-way screen through which the family therapist observes the therapy sessions is “analogous to the discovery of the telescope”; through this clear glass, we are now able to “view the fauna of a realm that had always been before us yet never truly seen.”

The new “bicameral” vision, created by the one-way screen, has indeed revolutionized the study of therapeutic interactions, since a therapist is able to observe from two places. For the first time, the therapist is able not only to observe his own contributions to the therapeutic relationship but also to have these monitored by a third person. However, Hoffman’s larger epistemological claim, based on the analogy of the screen, is naïve. Unlike the observer behind the screen, we are not in a position to step out of our conceptual schemes, shut the door, and enter a Kantian world of “things-in-themselves.”

Family therapy is particularly suited to people, such as children and psychotics, who are trapped in ongoing, intense, emotional relationships with their families. Family therapy is a group experience, its therapists usually working in pairs or teams. The family network, which is gathered into one room by the therapists, may comprise three or four or sixty people. Meetings may take place at regular times or they may be arranged when a crisis arises. Some therapists refuse to meet a family unless the whole network can be assembled; others will meet with individuals or subgroups. While family members express their grievances to one another, the therapists try first to uncover the structure of their relationships and then to formulate the most expedient plan for change so that the family system can function more beneficially. A large number of psychotherapy’s customers, however, are adults who feel trapped although they have physically separated from their families. These people do not need a therapist to step in to disrupt an ongoing system, but wish to free themselves from a past pattern of relationships.

Family therapy offers much that is new to the theory and treatment of mental dysfunction, and Hoffman has a good deal to say about the evolution and breakdown of the social system of the family. First, as her book so lucidly describes, the systemic viewpoint, borrowed from cybernetics, presents a radically different approach from both the medical model of mental illness and from Freud’s theory of psychic reality and motivation. Put simply, the family therapist looks at the patterns and rules of the relations governing a system. Any one person is no more than a passing element in a never-ending sequence. For instance, patients often switch places; as one gets well, another gets sick, all in the service of preserving a family’s internal balance.

Second, the overriding goal of family therapy is change. No one seems to care too much about “follow-up”—about who, or what, changes and into what—just so long as the malfunctioning system self-destructs. Many fascinating and highly effective techniques have been devised in pursuit of this goal. Hoffman portrays the family therapist as a trickster and bully, stage actor and director, a master of strategy and gamesmanship. Insofar as symptoms interest him, they are viewed as “harbingers of change,” the weakest links in the chain that binds the family. The symptom is always exploited as a source of disruption of the faulty system and never sedated. Needless to say, since the therapist works as an “agent provocateur” he or she is not usually seen as a kindly, sympathetic family doctor.

For example, a family seeks therapy because of the difficult behavior of the thirteen-year-old son at mealtimes. The mother may have tried to please her son by cooking his favorite dishes, yet all her efforts are met with scorn and disgust and her son continues to eat snacks out of the refrigerator. The problem, of course, does not lie in the nature of the food but in the changing relationship between mother and son—in particular, the shift from a complementary relationship to one of equality. The wily therapist might interfere by issuing the absurd prescription that the mother make her son two of his favorite meals during the next week and then sit beside him while he eats, perhaps offering to cut up his food for him. In addition, she might get out his baby cup. This ritual symbolizes the closeness both mother and son have to give up. Father is also told to eat the same meal. Hoffman points out that, although the aftermath is unpredictable, the ridiculous assignment often hits home and all the family members are forced to recognize their difficulty in saying goodbye to their old positions, even though on the surface they wish to be rid of them.

Family therapy began in the Fifties and flourished in the Sixties, inspiring a revolt against the medical establishment and, in particular, its treatment of schizophrenia. In the US and in Britain, its principal theoretical mentor has been the British anthropologist, the late Gregory Bateson. In psychiatry, Bateson is best known for his work on the “double bind,” an important pattern of communication in the syndrome called schizophrenia. A double bind is a communication on several levels in which an overt statement at one level is covertly nullified or contradicted at another. Drawing on Bertrand Russell’s work on logic, Bateson teased out the different levels of communication, which are mixed up in the schizophrenic’s “word salad” or “thought disorder,” and ordered them hierarchically.

At the first level, one person, usually in a subordinate or dependent position, is issued a command—say, “Eat your food”; at the next level, he is told not to obey by a message such as “Grow up and stand on your own two feet”; at a third level, he is forbidden either to comment on the contradiction or to ignore it—“You are too young and weak.” This last comment is particularly incapacitating for a child, who is dependent upon his parents for survival, but it is also constricting for people in institutions.

Although the early researchers in this field saw children and mental patients as the principal victims of double binds, most therapists now regard all participants as equally enmeshed in this paradoxical type of communication. Indeed, in his crazy-sounding statements, the identified patient may be the most skilled master of the double bind. In one of Hoffman’s examples, a young man sends a card from a mental hospital to his mother on Mother’s Day. On it are written the words “To One Who has been Just Like a Mother to Me.” In another example, a catatonic girl parries her father’s inappropriate advances to her by saying “Petting between teenagers sometimes gets out of hand.”

Many of the theoretical and technical developments in family therapy can be seen as expansions of Bateson’s original double-bind hypothesis. The pathogenic type of mother-child interaction, vividly portrayed in Laing’s original study of schizophrenia, The Divided Self, is now seen to extend across generations and to be a notable feature of three-person relationships. Hoffman describes family life as a “multi-generational changing of the guard.” Crises usually occur when members change places—during adolescence, at birth, marriage, retirement, or when a child goes to kindergarten. The double bind comes into play at these times to confuse and prevent disengagement. Suddenly, a teenage girl becomes anorectic, an eighteen-year-old college freshman develops a phobia, a child becomes asthmatic, or a mother falls prey to migraines.

The founders of family therapy were struck by the rigidity of disturbed families and by their resistance to the normal evolutionary processes of family life. Hence family therapy’s technical emphasis on strategies of change. In its early stages, the circularity of social systems was defined by the cybernetic concept of homeostasis. A homeostatic system is like a house thermostat in that it is self-regulating and conservative. Family interaction was viewed as a closed information system which sought stability and equilibrium. In malfunctioning families, so the family therapists thought, antihomeostatic, i.e., destabilizing, runaways had got out of control, thus leading the system to break down.

This view of the organization of living systems was consistent with Freud’s law of conservation, which he elaborated in his principle of the universal compulsion to repeat. But for some reason, presumably connected to their immersion in pathology, therapists have concentrated on the resistance of people to anything new rather than on the concomitant, though conflicting, desire for variation. Ethologists have been the first to point out the importance of the attraction of both the familiar and the strange throughout human development. We cherish home yet long for foreign places.

In recent years, again influenced by developments in cybernetics, family therapists have shifted their attention from the principles governing stability. According to such therapists as Salvador Minuchin, Paul Dell, Mara Selvini Palazzoli, and Lynn Hoffman herself, families are not closed systems. On the contrary, they evolve and transcend repetition. Families in a state of stress are now said to be unevolved in that they tend to avoid change. For them, reality is defined by loyalty and closeness. Murray Bowen, a pioneer of family therapy, initially viewed schizophrenia as the outcome of an unresolved symbiotic tie between mother and child. Expanding the psychoanalytic concept of mother-infant “symbiosis” to the intense interdependence of families, researchers have described family pathology in terms of an “undifferentiated family ego mass” (Murray Bowen), “pseudo-mutuality” (Lyman Wynne), “enmeshment” (Salvador Minuchin), and the “too richly cross-joined system” (W. Ross Ashby).

It may surprise a layman to hear that a rigid family system is “too richly cross-joined.” Surely, the channels of communication should be increased among the members of the family. On the contrary. Families do not function well when members talk too much and about each other. Lack of privacy sabotages the effort of any one element toward change. Any fluctuation precipitates a counter-flurry. The therapist must also guard against the tendency of closely connected systems to swallow up any variation, including his intrusions. His first task may be to block communication so that parts of the system can function independently.

Hoffman describes two prominent patterns of cross-connectedness: triangular formations and cross-generational coalitions. The so-called “perverse triangle” is a “cross-generational coalition.” A father may side with his daughter against his wife, or a mother may side with her mother-in-law against her husband. Surprisingly, two-person relationships rarely persist in malfunctioning families. Whenever a conflict arises, or an alliance is made, between two people—say, between a father and son or a brother and sister—a third person steps in to diffuse and confuse the original transaction. In this “infinite dance of shifting coalitions,” any one member, often a child, may be caught in a loyalty conflict between several opposing alliances. The unspoken demand to conceal the coalition increases the distress. In a family where there are two parents, two children, and two sets of grandparents, any person may be involved simultaneously in twenty-one triangles.

Freud’s concept of the Oedipus conflict may be compared with the systemic theorist’s concept of the perverse triangle in that both concepts underline the rule that Western family life is disrupted by secret, dangerous, cross-generational coalitions. As Hoffman points out, these are sanctioned in other cultures. In Hindu society, husband-wife closeness is discouraged as a possible source of distress to the joint family system. The cross-generational mother-son tie is upheld over ties that are created through marriage or peer group activities. Hindu society does not encourage the values of individualism and independence which, in Western societies, often clash with unspoken ideals of family solidarity.

In the US, eruptions in family life during adolescence may be symptomatic of these discordant social values. At one level, autonomy is encouraged while, at another, cross-generational intimacy and camaraderie inhibit the children from developing in their own distinctive way. In its extreme form, anorexia may represent a young girl’s desperate bid for independence. Through her refusal to eat, she is expressing her rejection of, and rivalry with, her mother while giving the impression of being a fragile doll.

Hoffman describes an initial interview between Salvador Minuchin and the family of a fifteen-year-old girl who had been hospitalized for anorexia, having fallen to a weight of about seventy-eight pounds. In his therapy with anorectics, Minuchin arranges for lunch to be served to the whole family, while he observes behind a one-way screen. In this example, the anorectic girl exploits a conflict between her parents, in which her mother reasons with her about her eating—asking her if she wants to eat, etc., while her father demands that she eat simply because he says so. The mother feels the problem would be solved if the girl were encouraged to take responsibility, whereas the father believes that the solution lies in asserting parental authority. The daughter is caught in this conflict. If she controls her own eating, she is disloyal to her father; if she follows her father’s orders, behaving like a child, she is disloyal to her mother. From the systemic point of view, the girl, who is the youngest child of the family, keeps the family from taking the next evolutionary step toward disengaging themselves from the ties that bind them.

Minuchin will sometimes succeed in breaking up the symptomatic cycle by his insistence that the parents get together to make the child eat. If this fails, he might encourage each parent to try their way with the child. When this fails—in the case cited, the mother becomes hysterical and the father violent—Minuchin intervenes and points out to the distraught parents that they have a daughter who is stronger than both of them. He thereby puts the parents together in an alliance and changes their characterization of their daughter from that of a little girl in need of intensive care to that of a forceful, rebellious young woman.

The supreme value of the systemic approach lies in its power to disrupt family systems of which it might be said, “Thou cans’t not pluck a flower without troubling a star.” Moreover, the incisive and strategic character of the family therapist’s interventions are well suited to larger “networks,” such as many of the traditional mental health institutions. The systemic therapist is able to perceive double binds that cut across different situations and groups, including those that occur between the “sick” and the “caretaking” agencies. More than any other school of therapy, family therapists have changed the treatment of institutionalized mental patients and have pointed out the devastating effects of institutions upon their already confused inmates. A child guidance clinic or traditional mental hospital, headed by a medical director, is organized to treat individual pathology. The doctor rarely considers the effects of the setting upon mental disturbance.

As early as 1954, Hoffman tells us, two organization theorists, Alfred Stanton and Morris Schwartz, linked conflicts among members of a mental hospital’s staff and outbursts on the ward to “the problem of the special case.” Structurally, the “special case” involves a triadic relationship very similar to that of the perverse triangle or improper family coalition. The patient’s “dissociative” disorder illuminated a covert disagreement between the conflicting staff attitudes, one authoritarian, the other permissive. In a day-to-day account of a dispute between a staff administrator and the patient’s therapist, the researchers found that the patient’s state fluctuated according to the intensity of the unexpressed disagreement. Once matters were talked out, the patient became less excitable and ward life returned to normal.

Hoffman also shows how the “ecological” school of family therapy has contributed to changes in community psychotherapy that have been especially helpful to the poor. Unlike enmeshed families, many underprivileged families can be described as “disengaged” in that they have poor cross-connections between parents and children, and they are frequently headed by an isolated mother without resources. E.H. Auerswald, a collaborator with Salvador Minuchin in the pioneer study Families of the Slums, developed an “ecological systems approach” in order to transform what he called the “total field” of a problem; the “field” included the professionals, extended family, community figures and institutions, like welfare, with which poor families have to contend. In New York’s Lower East Side, Auerswald set up a family health unit that was available twenty-four hours a day and operated out of a van—the Mobile Crisis Unit. This unit traveled from home to school to hospital to court, wherever trouble arose. Thus therapy is made available to people in communities where morale is low.

As in all therapeutic relationships, the technique of intervention is an act which reflects the training and personality of the therapist. Some family therapists are sociable and charismatic, others are quiet and self-effacing. In contrast to the American schools, for instance, the family therapists of the Milan group, as Hoffman describes them, have reinstated some of the more traditional qualities of neutrality and quiet inscrutability. Nevertheless, the art of the family therapist is specific. Like that of the Zen master, it evolves with his mastery of the double bind. The therapist not only flushes out the fundamental contradiction, he deftly turns the double bind back on his audience in the form of a “paradoxical injunction” or “process koan.” Family therapists have noticed that the symptom—say, a phobia—of which the patient appears to be a victim exerts an enormous amount of control over a family. The deliberate prescription of the symptom breaks up the hidden control and puts the patient in a dilemma. If the patient is to maintain control over his situation, which now includes his therapist, he must defy the therapist and abandon his symptom. If, however, he follows the therapist’s command, he must acknowledge his submission to the therapist. Family therapists enjoy, and indulge in, the drama afforded by a good symptom, turning, whenever possible, tragedy into comedy.

To illustrate the therapeutic use of the double bind, in which change is rewarded rather than thwarted, Hoffman describes a session with one of what she calls the “great originals,” the late Don Jackson. Jackson tells a paranoid, non-cooperative patient that, since he must think he is God, he, Jackson, will comply by treating him as if he really is God. Jackson then gets down on his knees and presents his patient with a large hospital key, saying that since he is God, he deserves to have the key more than his therapist. The astounded patient drops his stony demeanor and comes over to Jackson, saying “Man, one of us is certainly crazy.”

Another of Hoffman’s “originals,” Nathan Ackerman, takes a very bold approach to a marital conflict. Having pushed the bickering children—the family’s presenting symptom—out of the marriage bed, Ackerman “gets into it” himself. He asks the husband whether he does not find his wife “a good piece,” then proceeds to flirt with her, asking her, “How can you cooperate with me so beautifully, so juicy-like…and with your husband you don’t cooperate?” The grim couple are so taken aback by the therapist’s crude expressions that they begin to laugh, and then band together.

As these examples suggest, family therapists are playful; they participate in the drama of family life both as spectators (behind the one-way screen) and as actors. They are not afraid to escalate tension and conflict in order to gain the purchase which will enable them to change the pattern of family relations. Hoffman tells us how Carl Whitaker, a self-styled “therapist of the absurd,” once astonished a psychotic woman by first suggesting that she sit on her father-in-law’s lap and then commenting, “Incest is better than love.” If questioned about his reasons for such statements, Hoffman reports, Whitaker is likely to answer, “To please myself. If I don’t get something out of therapy for myself, I know it’s not going anywhere.” In the therapy of the absurd, spontaneity and fun become a criterion of therapeutic success.

In distinction to the American “bull-fighter” therapists, the more circumspect European therapists of the Milan group—to which Hoffman devotes her final chapters—sum up their position by the terms “hypothesizing-circularity-neutrality.” Hoffman places this more “intellectual” group, which grew up in the late Sixties around a child analyst, Mara Selvini Palazzoli, at the forefront of the family therapy movement.

Up to this point in her account of family therapy, Hoffman has upheld the ebullience of the Americans and devalued the more austere and quiet style of traditional therapists. However, within the movement and systemic thinking of family therapy, the latter qualities are seen as advantageous. The Milan group stresses that a hypothesis about a family situation must always be circular and relational and contain no trace of linear causality. This means that the therapeutic double bind, renamed “the positive connotation,” is no longer addressed to the individual patient presenting the symptom. Instead, all the behavior pertaining to the symptom is given a positive meaning for the whole family.

In addition, the Milan group has devised the technique of “circular questioning,” which aims to increase the amount and quality of information in the family system. “Circular questioning,” or “difference thinking,” is developed from Bateson’s definition of information as “a difference which makes a difference.” Schizophrenic families seldom notice differences and avoid defining relationships. Circular questions are designed to make people stop and think so that they articulate, rather than blur, their relationships. A therapist might ask several members of the family, “If you had not been born, what do you think your parents’ marriage would be like now?” Through their neutrality and four-person team approach, the Milan therapists avoid alliances and acting out their own personality traits. The leverage gained by being modest is more important to them than the pragmatic achievements of the bullying strategist.

The professional approach of the Milan group reminds us, as it does the author, that family therapy shares many of its qualities with other forms of therapy. Hoffman compares the Milan style to that of “the old-fashioned analyst with his impassive position behind the couch.” Hoffman’s view of the traditional analyst is of someone who would be bad in any profession; he is the man who follows the rules of the textbook—in this case, Freud’s early work—to the letter. I suspect that her picture derives from the kind of doctrinaire, over-solicitous, yet remote, doctor, who is enclosed in his characterless office and equates neutrality with passivity. Although the “benevolent” kind of analyst may be more common in the US, where the requirement of a medical training still dominates, and impedes, the advance of psychoanalysis and psychotherapy, most analysts (one hopes) are not like this. In Europe, where literature, history, philosophy, anthropology, cognitive psychology, and other intellectual disciplines are considered just as valuable as medicine to the aspiring analyst, many different approaches may coexist, clash, and flourish in one establishment.

Hoffman is mistaken in her claim that psychoanalysis has formed the basis for the US mental health establishment, which is built rather on the medical model of mental illness—diagnosis, prognosis, treatment, and cure. Indeed, the protectiveness and suspicion of other disciplines displayed by psychoanalysts in the US may spring from the fact that they themselves are not readily accepted by the medical establishment and are often scorned by hospital and clinic psychiatrists. Family therapy is unique in having opened its doors to nonmedical professionals. The diversity of backgrounds inevitably contributes vitality to a field; at the same time, the discipline is then open to charges of nonprofessionalism. Family therapists have been criticized for their manipulation of people’s feelings by dramatic techniques and for their grosser displays of egotism.

As with so much other writing on psychology, the usefulness of a new, but limited, idea—useful, in part, just because it is limited—is spoiled when it is expanded into a complete philosophy of life and expounded in an evangelical style. For instance, while Hoffman proselytizes for the systemic, circular approach, the psychologist Heinz Kohut preaches the virtues of the “introspective-empathic method”—a method which is firmly individualistic and subjective.^* Both methods bolster their claims by their opposition to the traditional Freudian, medically trained psychoanalyst. Both hold that one method is the correct response to reality. One wonders when psychotherapists will begin to follow their own definitions of normality, in which differences are tolerated and attitudes more appropriate to religious conversion are renounced. Despite their differences, psychoanalysis and family therapy might flourish from an exchange of concepts and therapeutic techniques.

Psychoanalytic theory and techniques have come a long way from the nineteenth-century model depicted by Hoffman. According to that model, “symptoms are said to arise from a trauma…that originated in the patient’s past and that has…been relegated to the unconscious.” Treatment consists in the “abreaction,” i.e., recovery and re-experiencing, of the repressed event and the “working through” of these buried emotions with the therapist. The therapist is portrayed as a “benevolent doctor of the soul, offering advice and support or acting as his client’s advocate or guide.”

This picture bears no resemblance to the founder of psychoanalysis. Many of the “revolutionary” attitudes assigned by Hoffman to the systemic therapist have characterized psychoanalytic practice for years. Any competent analyst is actively involved with his patient, monitors his own contributions, feelings, and reactions, which may be very intense, and uses these as the basis of his interpretations. Few therapists are now concerned with the total reconstruction of the past as the necessary and sufficient condition of cure. Like Hoffman’s family therapist, they use the past “as a source of momentum for change in the present,” believing that only in context of the present is “history…no longer dead but alive.” Hoffman’s family therapist is almost “phobic” about the past in that he sees any historical focus as leading to a dead end.

A psychoanalyst may open up the past not in order to dwell upon it but because he believes that only in the context of the past is the present “no longer dead but alive.” The reconstruction of the past provides both analysand and analyst with a perspective from which to view a present which seems unnecessarily restricted and repetitive. The way a person acts in the present makes sense when viewed as a reenactment of previous relationships and situations.

Analysts of the Object-Relations school, deriving from the work of W. Ronald Fairbairn, Melanie Klein, Michael Balint, John Bowlby, and Donald Winnicott, have long ago abandoned drive theory and the theory of psychic energy. They do not sit back, silent and mirror-like, but often enter into a spirited dialogue. Like the family therapist, they focus on the here-and-now relationship between analyst and analysand—the “transference” and “counter-transference.” Laing’s early work on schizophrenia, which is given scant acknowledgement by Hoffman, can be seen as a direct development of an influential tradition in psychoanalysis—the British middle school.

Another extraordinary allegation of the author is that, unlike the analyst, the systemic therapist is prepared to attract negative and hostile reactions and to acknowledge the patient’s creative contribution to the therapeutic process. Any analyst worth the name expects, even actively elicits, the “negative transference”—the disappointments, mistrust, despair, rage, and revenge—which he knows is essential to change.

In view of the current state of misunderstanding and the failure of practically all therapies to evaluate results systematically, an unbiased assessment of the respective therapeutic results of family and individual therapy seems impossible, and yet these two perspectives, incommensurable though not always incompatible, can contribute greatly to our understanding of personal relationships. The capacity to switch from one perspective to the other, sometimes attending to interpersonal matters, sometimes to private fantasies, exemplifies the binocular vision essential to the practice of psychotherapy.

To me, the major contribution of family therapy to the disciplines of psychotherapy and psychoanalysis is its original discovery, and clear elucidation, of the double bind. Paradoxical communications pervade ordinary human discourse. A child’s play, as the British psychoanalyst Donald Winnicott so brilliantly described it, involves a paradox. Play crosses inner and outer reality; it is both private and social. A doll is neither a real person nor a private fantasy. In his work with children, Winnicott used play as a way of entering into the private and frightening world of the child. The child and Winnicott would play a “squiggle game” in which each, in turn, would make something out of the other’s squiggle. Through this play technique, Winnicott gained the child’s trust and interest so that, together, they could explore the child’s fantasies and nightmares.

The psychoanalytic discovery of the “transference” itself involves a paradox. The analyst is a paradoxical figure for the analysand—intimate and yet not a friend in that he neither retaliates nor conciliates. The technique of the transference interpretation, like the paradoxical prescription, invokes a double bind. At one level, the interpretation contains a message about a particular content—say, a part of a dream or an anxious response to the therapist’s appearance. At another level, the patient is told that his feelings about his therapist are “real” and yet they are “fantasies” which do not strictly apply to him but to someone else in the patient’s inner or outer life. A new analysand may be painfully aware of this double bind when he says such things as, “But you aren’t really my friend. You don’t really care about me,” or “I don’t feel you’re my mother.”

The art of the transference interpretation depends upon the analyst’s skill in clarifying for himself these different levels. Therapeutic stalemate may result from confusions of level rather than from incorrect interpretations of content. Winnicott once described psychotherapy as “the overlap of two play areas,” warning us that the paradox must be tolerated and not resolved. The analyst must never allow himself to be saturated by the patient’s fantasy—say, of an ideal mother who hands out candy—and yet he must never say to an enraged analysand, “Look, I’m not your father. I really care for you and want to help you.” In his exploration of the paradox, Winnicott, like the family therapist, also noted that humor gives the therapist “elbow room.”

Winnicott was alone among analysts in his awareness of the power, danger, and magic of the double bind, which he called the “paradox.” Psychoanalysts, wary of psychosis, strategy, play, and even children, have been slow to recognize this third type of communication. Like Freud, they acknowledge the “secondary process” of logic and reason and the “primary process” of dream and private fantasy. For family therapy and psychoanalysis respectively, Bateson and Winnicott have addressed the most ordinary, yet enriching, level of human discourse—dreaming, playing, humor—which poets, artists, children, some mothers and grown-ups have never forgotten. Lynn Hoffman’s book, conceived within one school, still suggests connections with other approaches to experience. It would be a loss if the insights of Bateson and Winnicott were shared only among those who see themselves as part of one family or another.