Friday, July 20, 2012

Paradoxical Intervention

According to Mirriam-Webster, paradox can be defined as a statement that seems contradictory or goes against common sense, but is actually true, or a statement that seems logical but is actually self-contradictory. To some extent, paradox is inherent in therapy, because humans are contradictory creatures, on the whole, and a lot of the "messiness" of life is an expression of its paradoxes. However, sometimes therapists use paradox more intentionally, as part of a paradoxical intervention.


Paradoxical interventions are a kind of end-run around entrenched symptoms, client resistance or ambivalence, by asking the client either not to try to change symptom (behavior, thought, feeling), to actually try to increase it, or to pretend to have it. These instructions are paradoxical because the ultimate goal is obviously to alleviate the symptom - a goal that seems to be in stark opposition to what the client is being asked to do.

While paradoxical interventions are most associated with strategic family therapy, they have been used in a wide range of modalities and approaches. There are a few circumstances in which they are particularly helpful.

1) When attempts to lessen or control the symptom are actually making the symptom worse.

It often seems to be the case that the more we "try" to alter our internal state, the more elusive the desired result may seem. For example, if you are having trouble sleeping, "trying" to sleep just keeps you awake. Similarly, trying not to think something keeps that thought present in your mind. The act of monitoring yourself requires you to keep referencing the undesired thought. Trying not to feel something simply heightens your distress, most likely because labeling the feeling unwanted, bad, unbearable, or whatever, makes it something to be feared.

Paradoxical interventions in these cases may be to increase the frequency of the undesired thought/feeling/behavior, or even to simply observe it - to track it when it happens, and record observations, "to learn more about it" or "understand it better" before trying to change it. (In fact, monitoring in and of itself can decrease the symptom in question!)

2) When the client believes the symptom is inevitable, and not in their control

Clients often feel like symptoms are hapening to them, and believe they are powerless to influence the symptoms. In some sense, they give away the agency they do have by focusing on whatever is least within their control. In this context, paradoxical interventions become a demonstration that clients do in fact have some control over their symptoms.

Clients may be asked to increase the frequency or intensity of a symptom, or to schedule it for a particular day/time/location. If they are able to do so, they are clearly able to exert some voluntary influence over it. And if they are unsuccessful - well, probably that means that the frequency or intensity lessened instead, which actually moves them closer to their ultimate treatment goal.

3) When the client has tried several times to change a behavior, but has not been successful

When clients are really stuck, and have tried more straight-forward methods of change without success, they (and we) are liable to become more and more frustrated. In these times, it may be necessary to "shake things up" by changing course.

There are a few different paradoxical approaches that may help. The client may be encouraged to "pretend" to have the symptom (because, while they are pretending to have a symptom, they are not actually having the real symptom). If there are secondary gains or benefits that are associated with the symptom or behavior, it might also be possible to find a way to pair these reinforcers with the pretend behavior, eliminating the need for the real symptom. The client may be encouraged to schedule the symptom for a particular time and place - other than the time and place it usually occurs. This weakens the power of context to trigger the symptom through conditioning, and also brings it under more voluntary control...which can ultimately result in voluntarily stopping it completely.
Finally, they may also be asked to increase and/or observe the behavior - again, to learn more about how it operates, and with the hope that observation will paradoxically reduce the behavior.

Of course, all of these paradoxical interventions come with a caveat: they should only be undertaken when it is safe to do so. It could be disasterous to suggest a client increase violent behavior toward self or others! Paradoxical interventions should also only be used in the context of an established, positive therapeutic alliance. Finally, be sure to convey empathy and not sound sarcastic!

Have you used paradoxical interventions? How do you use them, and how do clients respond? What are the indications - and contraindications - for this type of approach?

No comments:

Post a Comment