Motivation and emotion/Book/2024/Paradoxical interventions

Paradoxical interventions:
How can they facilitate psychological change?

Overview

Case study

Daniel struggles with anxiety centered around his academic performance and is intensely afraid of academic failure. He goes to a session with his therapist and expresses his anxiety over the exam he is undertaking the next day. His therapist proposes an outlandish suggestion: "try your hardest to fail this exam". This prescription takes Daniel by surprise, he would never think to actively try to fail an exam, it is a ridiculous notion. This surprise, followed by newfound perspective and humour, causes Daniel to become more comfortable with the idea of "failing" (Browning & Hull, 2021; Delage, 2019; Peluso & Freund, 2023). His mind would not dare approach the idea of failing, but his therapist's suggestion allows him to approach the idea, anxiety cast aside. The uncontrollable anxiety he feels around the avoidance of failure, becomes more controllable as he humours the idea of actively "trying to fail the exam" (Gentelet & Widdowson, 2016). Daniel sits down for his exam the next day and thinks of what his therapist told him. Daniel cannot help but find it humorous and is relaxed due to the ridiculousness of the suggestion. Daniel then proceeds to do his best to fail. For the first time, Daniel found the ability to relax while doing the exam and passed.

This case demonstrates some of the principles of paradoxical interventions. Here there is a client who has intense anxiety around avoiding academic failure. So, our therapist suggests something counterintuitive, to fail the exam. Daniels anxiety is based on the avoidance of failing, this intervention asks him to approach failing. The surprise, followed by a perspective shift and humour causes Daniel to be less anxious about the idea of failing. Paradoxical interventions are based on the ability to catch the client by surprise, cause a shift in perspective and to find humour in this suggestion. - Based on a real interaction that Viktor Frankl had with a client (Browning, & Hull, 2021)

What if I told you that the only way to overcome your fear was to directly face it? What if I told you the only way to take control of your “problematic” behavior or habits is to keep doing it? What if I told you that the only way to overcome your struggle, is to let yourself struggle?

These ideas are at the heart of Paradoxical Interventions (PI). They are clinical techniques used to encourage flexibility in clients’ thinking and promote behavioral change (Peluso & Freund, 2023). PIs have different applications and variations which all provide similar positive results. Results being perspective changes, cognitive flexibility, acceptance, control over symptoms and more (Knab, Winter, et al. 2021; Munroe, Al-Refae, et al. 2021; Salim, Jansson-Fröjmark, et al. 2024). However, PIs have an interesting place in modern practice. They are not frequently used in contemporary clinical practice, not much is widely known in how and when they are effective, and PIs are not viewed positively by significant amounts of people (Browning & Hull, 2021). PIs are however an interesting topic to examine, thus the goal of this book chapter is to explain and discuss the concept of PIs in the context of psychotherapy and how they can facilitate psychological and motivational change. The discussion will be broken down as follows:

How can PIs facilitate psychological change?

1. What is PI and how does it work?

2. How and when are PIs effective?

3. How PIs fit into modern practice

What is paradoxical intervention and how does it work?

What is PI?

What PI is not: Reverse psychology

Before we discuss what, PIs are, lets discuss what they are not. PIs can be often viewed as "reverse psychology" which is a form of coercive control based on strategic self-anti-conformity theory (SSA; Browning & Hull, 2021). SSA is based on expecting defiance from a patient, telling them to do one thing, expecting them to do the opposite. Therefore, for the technique to be considered reverse psychology it requires the therapist to have a bias of an expected outcome. Where PIs differ, is the lack of this bias and directional control by the therapist. A therapist using PI makes a counterintuitive suggestion not expecting it to be contradicted, but rather to open the patients mind to alternative perspectives. From that expansion, the client is given autonomy, control and understanding of their situation. Take, the case study example of Daniel (see above). The suggestion was not an effort to make Daniel defy his therapist and try even harder to not fail. Daniel wished to avoid failure and that gave him great anxiety, he was already trying hard enough to not fail. So, when his therapist told him to try to fail his exam, this was done to disrupt the Daniels thought pattern to avoid failure. Daniel then is able to approach the idea of failing and not feel fearful of it - Daniel overcomes his fear. All this to say, that PIs are different to reverse psychology because PIs are not delivered in a way to manipulate the client into a certain behaviour. PI is used to disrupt negative cognitions, change perspectives and adopt positive, even humorous views on problems.

What PI is

PI is a therapeutic, psychological intervention technique that promotes cognitive flexibility and behavioural control (Knab, Winter, et al. 2021). This technique is used for individuals who suffer from specific problems that involve cyclical thinking, avoidance behaviours, and a lack of control over symptoms and behaviours. People who suffer from these problems experience a level of cognitive rigidity and struggle to control symptomatic behaviours and therefore need something to disrupt these struggles. PIs all disrupt cognitive rigidity and behavioural control by promoting cognitive flexibility and behavioural control.

There are separate PI techniques that demonstrate these two effects. Under the umbrella of cognitive flexibility, there is reframing and positive connotation, and in the group of behavioural control there is prescribing symptoms, paradoxical intention and paradoxical time tables. Each group of techniques are all similar in their goals and mechanisms but there are subtle and nuanced differences.

PI techniques: Cognitive flexibility

The PI techniques that mostly center around cognitive flexibility are reframing and positive connotation. Reframing is already a widely known and used therapeutic technique, but it is also to be considered a PI technique. Reframing is taking a situation, feeling, or behaviour and shifting the client's evaluation of it - typically turning a negative evaluation into a positive one (Munroe, Al-Refae, et al. 2021). This is a PI in the context of a client appraising the situation in one way and then being shown an alternative and counterintuitive way to view it. This oncemore results in a cognitive disruption in one's evaluation. Furthermore, positive connotation is a PI technique with a similar function. Positive connotation is the act of identifying a seemingly bad behaviour that the client enacts and attaching a positive notion to it (Delage, 2019; Peluso & Freund, 2023; Watson, 2012). Seeing the behaviour for its benefits rather than its harmful effects, stirs the individual's cognition allowing them to come to an understanding of why act the way they do.

PI techniques: Behavioural control

Additionally, PI techniques that pertain to giving control to the patient are prescribing symptoms, paradoxical intention and paradoxical time tables. Prescribing the symptom is - as the name suggests - the act of telling the client to perform the behaviour that they are likely trying to stop. Sometimes asking the patient to perform the extreme version of a symptom (Peluso & Freund, 2023). Prescribing a symptom to the client demonstrates to the client that they can conjure the symptom and therefore control it (Gentelet & Widdowson, 2016). Therefore, giving control to the patient. Furthermore, there is paradoixcal intention which is - similar to prescribing a symptom - encouraging the individual to do or wish to do the thing they want to avoid (Browning & Hull, 2021). If the most salient part of a stressful task for an individual is an internal factor (e.g. heart rate, sweating, etc.) then the patient can be asked to try to augment this symptom (Ascher, 2002). The focus that comes from trying to augment an internal symptom actually relaxes the client or may perhaps become so sensitised to the stimulus that it no longer provokes an anxious reaction. Once more, the client gains control over what was once uncontrollable. Finally, paradoxical time table is also much like prescribing symptoms but at scheduled times of the day (Ahmadi, Rezaei, et al. 2020). Having specific times of the day when the client has to experience their symptoms then and only then, grants control to them. This can even help patients with managing their symptoms as they can work their daily schedule around these set symptom-experiencing times. Moreover, giving control to the individual.

How does PI work?

The explanation of how PIs work is closely tied to the aforementioned effects stated in the previous section. PIs promote cognitive flexibility and behavioural control. These things are incredibly effective therapeutic outcomes that many other therapy theories strive to achieve, such as CBT and ACT.

Cognitive flexibility is a valuable therapeutic outcome because it disrupts unhealthy cognitions, provides the individual with understanding and acceptance, and allows them to view things from alternative, and more healthy perspectives. Firstly, cognitive flexibility disrupts unhealthy cognitions. Many conditions that PIs are used to treat often involve unhealthy and cyclical thoughts. PIs with the elements of humour, surprise and cognitive shifting, disrupt these thoughts (Browning & Hull, 2021; Delage, 2019; Hameiri, Nabet, et al. 2018; Salim, Jansson-Fröjmark, et al. 2024). Meaning, when the patient identifies the humour or irony, is taken aback by their therapist's remarks, and take a glimpse at an alternative perspective they can approach their problem with a new, healthier headspace. Secondly, cognitive flexibility leads to the individual understanding and accepting themselves, their thoughts and behaviours (Browning & Hull, 2021; Munroe, Al-Refae, et al. 2021; Salim, Jansson-Fröjmark et al. 2024; Watson, 2012). Clients can achieve self-compassion when they come to understand the function of their bad habits and symptoms. This self-compassion and understanding are important to nurturing the self and changing these negative thoughts and behaviours according to principles of ACT and CBT. PIs therefore also evoke this valuable therapeutic outcome. Thirdly, cognitive flexibility permits the patient to view things from different and healthier perspectives. As stated before, many people suffering from mental health conditions have a rigidity in their appraisals, cognitions and reactive behaviours. What may be needed is a new perspective that was not previously obvious or apparent before the intervention. This change in perspective can be liberating and can help the individual find alternative solutions. Futhermore, cognitive flexibility is a valuable therapeutic outcome due to its capacity to disrupt unhealthy cognitions, providing understanding and acceptance and see new perspectives.

Behavioural control is an invaluable psychotherapy outcome because it gives the patient the strength and freedom to change, makes symptoms manageable, and gives the patient an unprecedented level of confidence and joy. Primarily, behavioural control is crucial because it illuminates the individual's strength and capacity to change. PI techniques demonstrate to the patient that they can experience their symptoms and therefore control them (Genteket & Widdowson, 2016; Peluso & Freund, 2023). This sense of control can then lead to the capacity to change. Secondarily, management of symptoms is another important result of behavioural control. Symptom management is a valuable skill for any patient to achieve as it will help reduce overall distress and increase regular functioning. Tertiarily, behavioural control grants a sense of confidence and joy in the client. Confidence and joy allow for the patient to move forward and progress in their psychological journey. Therefore, behavioural control is an invaluable psychotherapy outcome because of the strength and freedom to change, management of symptoms and the feelings of confidence and joy granted by PIs.

How and when are paradoxical interventions effective?

Considerations before using PI

There are generally three consistent requirements for PIs to be effective in their functions. PIs are most effective when the relationship between client and therapist is very healthy, when PIs are used cautiously and without directional intent, and with patients who experience conditions that cater to the strengths of PI. Foremostly, PIs are effective when used in a positive therapeutic context (Peluso & Freund, 2023). This is because PIs can sometimes be received negatively, however that is only if the client does not already trust and respect their therapist. PIs can be viewed as ridiculous, manipulative, and frustrating, meaning, if there is a strong therapeutic alliance these techniques can be very effective. In addition, PIs are most effective when used in a cautionary and without directional intent because the techniques can be misused to illicit desired responses. Evoking principles of reverse psychology, where the therapist aims to tell the client to do one thing expecting them to do the opposite. This is unethical and coercive and therefore should be avoided, lest the point of PIs be missed. Point being to generate cognitive flexibility and promote behavioural change that is ultimately determined by the individual. Lastly, PIs mostly only work in cyclical conditions. For example, someone who has a fear of failing may need that fear and stress to succeed in their goals, therefore if we attempted to eliminate that fear, it may result in a less desirable effect. Ideally, for PI to be used, this person would have to be someone who simply fears the anxiety they feel when put to a task that will result in either success or failure. In this instance, PIs can then be used to make the person accustomed and comfortable with the idea of failing, which is more in line with the function of PIs. Altogether, PIs are consistently effective when there is a healthy therapeutic relationship, when used cautiously and without coercive intent and when the condition the client struggles with suits PIs strengths.

When PIs have been effective

PIs have been practiced in research and clinical contexts and have been consistently found to be effective in treating a variety of conditions and causing other psychological changes. Conditions being anxiety, family dysfunction, OCD, insomnia, procrastination and psychological changes being in social/political contexts. In Gentelet and Widdowson's (2016) case study, they examined the effects of PI on a patient with recurring anxiety attacks. By prescribing the symptoms of the client's anxiety attacks, the attacks became controllable and manageable for the client. Delage (2019) describes using PI (positive connotation and symptom prescription) as a means of surprising and destabilising family attitudes and behaviours causing resulting in functional exchanges and productive problem solving in families. Ahmadi, Rezaei, et al. (2020) used paradoxical time table therapy to treat participants with OCD. It was found that the treatment led to participants challenging their problems/symptoms and caused them to alter their maladaptive beliefs. Salim, Jansson-Fröjmark, et al. (2024) propose a study that will evaluate the effect of PIs on insomnia. Due to the involuntary nature of falling asleep, research has demonstrated that PIs can be helpful by telling the participants to try to gently stay awake at night. This intervention has lead to participants falling asleep easier because their goal is no longer to fall asleep. Erde and Klingsieck (2018) discuss briefly the effective use of PIs on people who struggle with procrastination. Instructions to actively procrastinate at certain times, helped reduce procrastination frequency. Finally, PIs have been evaluated in being able to promote attitude change about social issues. Bar-Tal, Hameiri, et al. (2021) and Knab, Winter, et al. (2021) found that PIs were able to solicit cognitive flexibility in attitudes towards refugees and other social topics. All this is to show that PIs have a variety of conditions and contexts that they can be used effectively.

How paradoxical interventions fit into modern practice

PI in present

Where do PIs fit into present day practice? Their position is an interesting one as PIs are not frequently and widely used in modern clinical practice, however PIs are somewhat inherent to other forms of practice, furthermore there is still a stigma to PIs that is yet to be fully dispelled. First of all, PIs are not frequently and widely used in contemporary clinical practice. There are not many therapists who specialise in paradoxical treatments, there are not many resources that exist that teach how to use PIs and PI techniques are not fully operationalised (Peluso & Freund, 2023). What this means is that PIs are not at the forefront of clinical practice and are limited by this lack of focus. On the other hand however, PIs are still innate to come psychotherapy practices. Biggest examples being, the technique of reframing, ACT, CBT and dialectic practices. Reframing is a widespread technique and an incredibly valuable one that has elements of PI to them, in that they promote cognitive flexibility (Deschrijver & Palmer, 2020). The acceptance and understanding previously discussed are key parts to ACT and CBT and dialectic practices are based on contrasting things with their opposite to create alternative meanings (Hatoum & Burton, 2024). Consequently, PIs are somewhat inherent to some forms of modern psychology practice. Lastly, PIs do still inhabit a stigmatised environment in the research field. Reverse psychology will always be mentioned in the same breath as PIs, and the lack of regulated and effective teaching and practice of PIs only contributes more to the lack of respect felt by a significant portion of psychology researchers (Browning & Hull, 2021; Peluso & Fruend, 2023). To summarise, PIs have a very interesting place in modern practice as it is not frequently used in today's practice, while still being incorporated into aspects of modern practice, as well as having stigmas and misconceptions surrounding it.

Quick Quiz

Conclusion

To summarise, PIs are a form of psychotherapeutic intervention that generate cognitive flexibility and promote behavioural control. PIs come in the form of symptom prescription, positive connotation, reframing, and paradoxical intention that all achieve some level of cognitive flexibility and/or behavioural control. They can only be used effectively in certain circumstances such as in a health therapeutic alliance, should only be used with caution and without directional/coercive intent, and work best with conditions that cater to the strengths of PI. PIs have been used effectively in a variety of contexts and have been used to treat many conditions such as insomnia, anxiety, OCD, family dysfunction and more. However, despite the positive results, PIs are not used widely or frequently in modern clinical practice, they have an inherent, minor presence in other forms of psychotherapeutic practice, and they have an attached stigma that makes it difficult for it to be recognised as a legitimate therapeutic practice.

References

Ahmadi, S., Rezaei, A., Semani, S., & Kazemi, S. (2020). Comparing the effect of exposure and response prevention and paradoxical time table therapy techniques on the obsessive-compulsive disorder patients. Journal of Internal Medicine Today, 26(3), 244–259. https://doi.org/10.32598/hms.26.3.3093.3

Ascher, L. M. (2002). Paradoxical intention. In M. Hersen, & W. Sledge (Eds.), Encyclopedia of psychotherapy (pp. 331-338). Academic Press. https://doi.org/10.1016/B0-12-343010-0/00161-6

Bar-Tal, D., Hameiri, B., & Halperin, E. (2021). Chapter three – Paradoxical thinking as a paradigm of attitude change in the context of intractable conflict. In B. Gawronski (Ed.), Advances in experimental social psychology (pp. 129–187). Academic Press. https://doi.org/10.1016/bs.aesp.2020.11.003

Browning, S., & Hull, R. (2021). Reframing paradox. Professional Psychology: Research and Practice, 52(4), 360–367. https://doi.org/10.1037/pro0000384

Delage, M. (2019). Surprise and change in family therapy. Dialogue, 2019(1), 47–68. https://doi.org/10.3917/dia.223.0047

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Deschrijver, E., & Palmer, C. (2020). Reframing social cognition: Relational versus representational mentalizing. Psychological Bulletin, 146(11), 941–969. https://doi.org/10.1037/bul0000302

Erde, W., & Klingsieck, K. B. (2018). Overcoming procrastination? A meta-analysis of intervention studies. Educational Research Review, 25(1), 73–85. https://doi.org/10.1016/j.edurev.2018.09.002

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Hameiri, B., Nabet, E., Bar-Tal, D., & Halperin, E. (2018). Paradoxical thinking as a conflict-resolution intervention: Comparison to alternative interventions and examination of psychological mechanisms. Personality and Social Psychology Bulletin, 44(1), 122–139. https://doi.org/10.1177/0146167217736048

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Lanza, C., Christine, M., & Riepe, M. W. (2018). Positive mood on negative self-statements: Paradoxical intervention in geriatric patients with major depressive disorder. Aging & Mental Health, 22(6), 748–754. https://doi.org/10.1080/13607863.2017.1306834

Munroe, M., Al-Refae, M., Chan, H. W., & Ferrari, M. (2021). Using self-compassion to grow in the face of trauma: The role of positive reframing and problem-focused coping strategies. Psychological Trauma: Theory, Research, Practice, and Policy, 14(S1), S157–S164. https://doi.org/10.1037/tra0001164

Peluso, P. R., & Freund, R. (2023). Paradoxical interventions: A meta-analysis. Psychotherapy, 60(3), 283–294. https://doi.org/10.1037/pst0000481

Salim, O., Jansson-Fröjmark, M., Sandlund, C., & Norell, A. (2024). Paradoxical intention as a treatment for insomnia disorder: Study protocol for a mixed-methods pilot trial. BMJ Open, 14(10), Article e086676. https://doi.org/10.1136/bmjopen-2024-086676

Watson, W. H. (2012). Family systems. In V. S. Ramachandran (Eds.), Encyclopedia of human behavior (2nd ed., pp. 184–193). Academic Press. https://doi.org/10.1016/B978-0-12-375000-6.00169-5

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