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?

Escaping the Waiting Place

In his guide to life, "Oh, The Places You'll Go," the sage Dr. Seuss warns readers about:

"a most useless place. The Waiting Place...for people just waiting. Waiting for a train to go, or a bus to come, or a plane to go, or the mail to come, or the rain to go, or the phone to ring, or the snow to snow, or waiting around for a Yes or a No, or waiting for their hair to grow. Everyone is just waiting. Waiting for the fish to bite, or waiting for wind to fly a kite, or waiting around for Friday night, or waiting, perhaps, for their Uncle Jake, or a pot to boil, or a Better Break,
or a string of pearls, or a pair of pants, or a wig with curls, or Another Chance. Everyone is just waiting."

 

Most of us can probably relate. I think most people find themselves, at various points in our lives, feel like we have to put everything else on hold while we're waiting for...whatever it is we're waiting for. We wait to grow up, to go to college, to finish college, to get the perfect job, to buy the perfect house, to find a spouse, to have a family, for our kids to walk, start school, finish school...etc. We can spend most of our lives waiting for some future point to really live!

The same pattern can play out in therapy. All too often, clients say they "aren't ready" to change their behavior, or talk about/work on something sensitive, or take whatever risk they need to take to reach their life goals. They want to wait - until it stops hurting, or they stop having distorted thoughts, or completely resolve the last little bit of ambivalence, or stop feeling depressed (angry, anxious, whatever), or "get over" their grief, or forgive someone, etc., etc., etc.

Dr. Seuss does not happen to offer any sage advice on escaping the Waiting Place (he writes only: "Somehow you'll escape all that waiting and staying. You'll find the bright places where Boom Bands are playing"). However, barring a boom band showing up in our offices, therapists are challenged to find creative ways to help our clients break out of their "waiting."

I think it starts with psychoeducation. At its heart, waiting is the result of inaccurate or distorted thoughts or beliefs about the nature of feelings, thoughts, and actions. For example, people often operate on the assumption that feelings are an accurate basis for, or inevitable determinant of behavior. Based on this assumption, people who are depressed often say that they'll get up, shower, get dressed, socialize, etc, once they "feel better." However, research suggests that people begin to "feel better" once they start getting up, showering, socializing, etc. (an approach called Behavioral Activation). Identifying, and providing education to counter, the inaccurate assumptions impeding the client from taking necessary action is an important first step.

Even with this foundation, clients may still be stuck in the Waiting Place. Here's the hang up: we judge the veracity of new information based on how it fits with our experience. Without taking action, clients have no new information to test out the accuracy of what we want them to believe. But, they don't want to take action until they believe the new information. We have a few options in this sort of stalemate. We can continue trying to "talk them into" believing the new information. We can facilitate "vicarious learning" by pointing to others whose experiences provide support for the new information. Or, we can encourage clients to test it themselves in a small experiment. Instead of committing to sustained effort or change, they can just try it for a limited time or in a limited frequency, and self-monitor for any changes in how they feel (the experiment should be long enough to provide accurate information, however!). Finally, we can reach for any past experiences the client may have had that provide supporting evidence.

What other strategies do you have for helping clients (or yourself) escape the Waiting Place?

When is a Crisis Evaluation More Than a Crisis Evaluation?

One of my clients, who has OCD, sometimes has intrusive thoughts (i.e., obsessions) about hurting himself or someone else. In the past, he has acted on compulsions to non-suicidal self-injury, but never harmed anyone else, nor attempted suicide. Most of the time, he has the thoughts without acting on them.

Instead, he tends to present to emergency rooms for crisis evaluation and level of care assessment. He went through a period a few years ago, before I met him, of frequent hospitalizations. Then he transitioned to frequent partial hospitalization program admissions. Now, he's usually just referred back to his outpatient providers.

In spite of the steady decrease in his rate of admission to higher levels of care, he's  been getting evaluations with increased frequency over the last few months, creating something of a puzzle for me: If these evaluations are not about being admitted to a higher level of care, then what are they about?

I have a few theories on the matter, or course. For one thing, I have been somewhat less available during this time, with holidays and a new full-time job, so the role of his attachment to me (and related transference) in helping him feel safe could be a factor. He declined a referral to a therapist with more availability (again likely due to attachment), but perhaps occasionally needs a "booster" intervention, which he seeks out via crisis evaluation.

Whether or not my own availability has played a role, it seems clear that the crisis evaluation plays some sort of symbolic role for him. It's not a specific crisis service or clinician, since he presents at various local emergency/crisis locations, so it must be the process itself. One possibility is that the crisis evaluation serves as a kind of transitional object representing the treatment relationship with me and his psychopharmacologist.

Another possibility is that the crisis evaluation itself has become part of the compulsion - perhaps a kind of sublimation of the initial compulsion to harm self/others. In other words, the compulsion to harm is diffused by acting on the compulsion to seek crisis services. Alternatively, getting a crisis evaluation may also be a kind of "safety behavior" diffusing the anxiety in another way: he doesn't trust himself to 1) stay safe, and/or 2) know whether or not he can stay safe. Having a clinician and doctor tell him he's safe to go home provides the reassurance he needs to actually go home and be safe.

Normally, the treatment of choice with safety behaviors is exposure and response prevention - however, the risks of that treatment are considerably higher when the compulsion is about risk. While I'm pretty sure someone can not wash their hands and still come out in one piece, interrupting this safety behavior could result in harm to self or others. I'd rather he get the evaluation than act on a dangerous compulsion!

Instead, I'm thinking that harm-reduction may be the way to go. Since he has needed less and less intensive treatment over time, continuing the work will hopefully lead to less need for evaluations as he trusts himself more to stay safe. If anyone has another idea, though, I'm all ears!

Journaling: An Intervention We Can All Agree On

Journaling - the act of writing out one's thoughts and feelings - has been done in one form or another for centuries. Much of what we know about great historical individuals comes from their own writing. Authors and spiritual/religious figures have found a natural affinity with the practice, as have scholars from myriad disciplines (witness the journals of Da Vinci). Even a blog like this one is a form of journal.

It's of no surprise, then, that therapists have come up with ways to harness the practice of journaling as a clinical intervention. After all, much of therapy involves trying to put one's internal experiences into words. Perhaps the bigger surprise is just how widely applicable journaling is, across diverse approaches to practice.

1) Cognitive-Behavioral Approaches 
    Journaling is a logical part of CBT and related approaches. Recording one's thoughts can be the first step in changing dysfunctional patterns. Tracking behavior can be enlightening to therapist and client alike, and simply tracking a given behavior can change its frequency. If mindfulness - awareness of the present moment - is a goal, a journal can be a place to practice recording all of one's present experience. I could go on, but you get the idea.

2) Psychodynamic Approaches
    Journaling is used quite differently is psychodynamic or psychoanalytical therapy - as a way of moving things from the unconscious or subconscious mind to the conscious mind. This process often involves free association (writing everything that comes to mind without censoring), from which themes can be identified over time. It may also include recording dreams and fantasies.

3) Existential and Humanistic Approaches
    These approaches focus on tapping into one's innate capacity for growth or adaptation by fostering awareness of the present moment, and matching one's thoughts, feelings, and actions with that awareness. Journaling can be used as a way of developing awareness of the present moment, as well as identifying those things that distract or detract from awareness.

4) Postmodern Approaches
    This category of approaches, which reject the idea of objective truth, instead seeing all reality as socially constructed, and therefore changeable. The most common postmodern therapies are Narrative Therapy and Solution-Focused Brief Therapy. Given these approaches' emphasis on helping clients to construct their own preferred versions of themselves and their lives/futures, journaling can be a place to practice constructing, and to "try on" different constructions. Furthermore, in Narrative Therapy, documents have a vital symbolic role in the change process, and a journal is of course a document.

Do you use journaling as a therapeutic intervention, and/or in your own personal life? How do you approach it, and how have you seen it help (or not help)?