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Cool Intervention #8: Paradoxical Interventions

10CTI: Don't think about a paradox.

You know, this contribution to the Ten Coolest Therapy Interventions isn't very interesting. I wouldn't waste your time reading about the fascinating and controversial world of paradoxical interventions or the interview with one of psychology's living legends: Cloe Madanes. Kindly move along to the next blog.

Okay, read if you must, but definitely don't send it to a friend. Or leave a comment.

Paradoxical interventions involve prescribing the very symptom the client wants to resolve. It's a complex concept often equated with reverse psychology.

For example: The client fears failure, so the therapist asks the client to fail at something. A man has problems with procrastination, so the therapist asks him to schedule one hour a day to procrastinate. Your 4-year-old resists brushing her teeth, so she's told she isn't allowed and may end up doing it out of spite. Or a woman who can't initiate sex with her husband is advised not to initiate for a month. Don't think about a purple elephant. It's asking for something in order to achieve the opposite result.

The underlying principle is that we engage in behaviors for a reason, which is typically to meet a need (rebellion, attention, a cry for help, etc). In prescribing the symptom, the therapist helps the client understand this need and determine how much control (if any) they have over the symptom.

By choosing to manifest the symptom, they may recognize they can create it, and therefore have the power to stop or change it.

You can see how this might get a bit dicey. If the symptoms could cause harm to the client or anyone else, nudging the client toward it would pose an ethical problem. In fact, much has been written to establish guidelines for paradoxical interventions. Only clinicians well-trained in the technique should consider using it.

It's a privilege to interview Cloe Madanes, a pioneer in the field of family therapy and a prolific writer, speaker and fellow PT blogger. She wrote the book on Strategic Family Therapy, a modality that looks at the balance of power within the family and the hidden function of symptoms.

Her work continues to grow and evolve — she's recently joined forces with Anthony Robbins to find solutions to interpersonal conflict, violence prevention, and creating a civil community (watch them work together here).

On to her interview:

1. When would a clinician use a paradoxical intervention?

A clinician would use a paradoxical intervention when there is a clear symptom or presenting problem that the patient believes is an involuntary behavior, such as depression, fears, pain, even seizures.

2. What does it look like?

The therapist asks the patient to deliberately have the symptom at the therapist's office and/or outside the office. Family members may be asked to encourage, advise or reward the behavior.

The idea is that, if a symptom is involuntary, having it voluntarily means the behavior can be controlled and is no longer a symptom. If the person can have it voluntarily, this means he/she can also not have it voluntarily.

A variation is to ask the patient to pretend to have the symptom. When a person is pretending to have a symptom, they are not having the real symptom. Secondary gain or positive reinforcement can be arranged for the pretend behavior so that it replaces the involuntary behavior. The involuntary behavior is no longer needed in order to obtain the secondary gain.

3. How does it help the client?

It helps the client to be in control of his/her behavior and experiences. It's based on humor because the intent is for the patient to laugh at the idea of bringing on an unpleasant symptom voluntarily, and humor is always therapeutic.

4. In your opinion, what makes paradoxical interventions cool?

Paradoxical interventions are cool because they are painless and funny.

More from Ryan Howes PhD, ABPP
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