Paradoxical Intervention

Numerous definitions of paradox have been offered that contain several commonalities. First, they involve a statement that is contrary to received, or common, opinion. Second, they involve some sort of logical contradiction. For example, in ancient Crete, Epimenides the Cretan said, “All Cretans are liars”—which leads to a logical contradiction because he cannot be believed, whether or not he is telling the truth. Third, they often involve an explicit communication that is embedded within an implicit framework that communicates a different message. The famous “I want you to be more spontaneous” injunction is an example, because the explicit message can only be obeyed if it is not obeyed. This is a double bind, which some consider the essence of paradoxical statements. The paradoxes inherent in such statements are not easily disentangled and often can be resolved only by leaving the relationship entirely. Fourth, paradox can be seen as an example of dialectical thinking in philosophy, in which any statement may contain its opposite. It can be seen from these definitions that the key word behind paradox is contradiction.

Within a help-seeking counseling relationship, paradoxical interventions can be seen as those in which the counselor seems to advocate the continuation or even the worsening of problems rather than their elimination. Some writers see this as decontextualizing the problem by altering the context and the supporting environment in which the symptoms appear. In the process, the symptoms are redefined as solutions.

Paradox in Ordinary Life

Paradoxical ideas and ways of thinking are as old as humanity, especially in Eastern philosophy and major world religions. The Tao Te Ching (Way of Virtue), written by the founder of Taoism, Lao Tzu, contains much paradoxical advice, such as getting what one wants by being open to receiving its opposite. Buddhism likewise contains many paradoxical ideas. For example, if one seeks enlightenment, one will be unable to attain it because he or she will have attachment to enlightenment itself. Christianity contains many paradoxical statements such as, “Whoever would be great among you must be your servant.”

In lay terms, paradox is similar to reverse psychology, and many examples can be found in literature. Reverse psychology is a term that describes a situation in which advocacy of one course of action persuades someone to do the opposite. Examples include Tom Sawyer persuading his friends to paint his fence by describing it as a privilege rather than a task. Likewise, attempts to censor works of art or literature paradoxically result in those works becoming more attractive.

Paradoxical Intervention in Counseling

Alfred Adler is widely thought to be the first therapist to make explicit use of paradoxical interventions. The use of these techniques stemmed from Adler’s belief that a successful power play against the therapist results in increased patient self-esteem and therefore patient improvement. Thus, in a sort of “therapeutic judo,” Adler encouraged patients to rebel against him. Adler often used humor in prescribing his injunctions.

From a behavioral point of view, in the 1920s, Knight Dunlap developed an approach that he called negative practice. This involved deliberately practicing behaviors that one wanted to eliminate rather than attempting to avoid them. Dunlap saw this as a way of bringing them under control. In doing so, he argued against the law of habit formation, which states that repetition of a response increases the probability of its recurrence.

Perhaps the best known therapist to use paradoxical interventions and the first to use that term explicitly was Viktor Frankl. As part of his logotherapy, he developed what he called paradoxical intention, in which he encouraged patients to do or wish for that which they most feared. For example, a patient who was very afraid of contamination was urged to wish to become as dirty as possible. This is very similar to what later was called symptom prescription.

Types of Paradoxical Interventions

There are different ways of classifying paradoxical interventions, but one useful system makes a distinction between compliance-based and defiance-based interventions. All of the specific paradoxical techniques can be placed within one or the other.

Compliance-Based Interventions

These interventions are used with the expectation the client will comply with the counselor’s suggestion or directive and thereby improve. In the original compliance-defiance model, clients who were low on psychological reactance, that is, the tendency to resist interpersonal influence, were expected to do best with these strategies. There are several types of compliance-based interventions.

Reframing

Also called positive connotation, this involves a shift in meaning of the problem behavior from negative to positive. For example, feeling depressed might be reinterpreted as exquisite sensitivity to one’s internal feelings and a willingness to make sacrifices for the good of others. Anxiety might be reframed as a strong sense of caring about the outcome of a task. A related technique is relabeling, in which the label of a problem behavior is changed without changing its meaning. Negative connotation can also occur, in which a positive behavior is relabeled as negative, but that rarely occurs because there is little point.

Symptom Prescription

This strategy involves urging the client to perform or even exaggerate the very behavior that is the problem in the first place. As a compliance-based intervention, it derives its power from the new control the client has over a behavior that was formerly seen as uncontrollable. A variant is symptom scheduling, in which the client is directed to (for example) feel deliberately anxious or fight with his or her spouse at a particular time. By implication, if the behavior can be controlled in one direction, it can be controlled in the other. This technique is very similar to Frankl’s paradoxical intention.

Defiance Based Interventions

These interventions are used with the expectation the client will defy the counselor’s suggestion or directive and thereby improve. They are similar to Adler’s original conceptualization. In the original compliance-defiance model, clients who scored high on psychological reactance were expected to do best with these strategies because they would resist the therapist in order to maintain their freedom.

Symptom Prescription

Although listed as a compliance-based intervention, this can also be conceptualized as a defiance-based intervention. With reactant clients, it derives its power from the fact that client resistance to the counselor’s suggestion or directive to perform the problem behavior deliberately reduces the frequency of that behavior. By implication, the behavior is under more conscious control than the client originally thought. Reactant clients tend to resist symptom scheduling as well, often finding it more onerous than simply giving up the problem behavior.

Restraining Strategies

In using this technique, the counselor either tells the client not to change the problem behavior (prohibiting change) or to change very slowly and carefully (inhibiting change). With this directive, reactant clients can resist the counselor only by changing, which is the point of therapy in the first place. It also empowers clients by placing the locus of change squarely upon them. The most common use of restraining strategies has been in sex therapy, where impotent couples are told not to attempt to engage in sexual activity for a period of time. With the pressure to perform thus removed, spontaneous sexual activity often occurs, much to their surprise.

Positioning

Here the counselor deliberately exaggerates clients’ negative views of themselves; useful when the counselor suspects these negative statements are designed to elicit positive comments from others in a “fishing for compliments” exercise. Adlerian therapists refer to this as “spitting in the client’s soup.” This technique should be used judiciously to avoid sounding sarcastic or uncaring. It should not be used with clients who have a truly negative view of themselves.

Effectiveness of Paradoxical Interventions

The research evidence has shown that paradoxical interventions are effective, although not more so than alter-native treatments. It does appear, however, that their effectiveness increases more over time than that of other treatments. Two possible reasons have been suggested for this “sleeper effect.” First, paradoxical interventions, by their very nature, may require a period of incubation as clients reorganize their cognitive meaning system. Second, they may result in clients’ attributing behavior change to themselves rather than to the counselor, thus leading to a sense of personal empowerment.

Some concerns have been raised about the acceptability of paradoxical interventions, or even if they are ethical. Although the evidence is sparse and somewhat mixed, it does suggest that counselors who use paradoxical interventions may be viewed less positively and seen as more manipulative. In addition, there is evidence that paradoxical interventions are seen as less acceptable. An explanation of the rationale behind these interventions may help the client be more accepting of these interventions. Of course, that removes some of the mystery that some writers believe is an important part of the counseling and psychotherapy process.

References:

1. Ascher, L. M. (1989). Therapeutic paradox. New York: Guilford Press.
2. Dowd, E. T., & Trutt, S. D. (1988). Paradoxical interventions in behavior modification. In M. Hersen, R. M. Eisler, & P. M. Miller (Eds.), Progress in behavior modification (Vol. 23). Newbury Park, CA: Sage.
3. Weeks, G. R. (1991). Promoting change through paradoxical therapy (Rev. ed.). New York: Brunner/Mazel.

See also:

• Counseling Therapy