Paradoxical Intention: What It Is And How This Technique Is Used In Psychotherapy
When the patient goes to the consultation, the therapist is expected to apply all types of techniques focused on reducing, in a very direct and clear way, any symptoms that cause discomfort.
One hopes that if you suffer, for example, insomnia, the psychologist will treat you with some type of relaxation and dynamics to avoid worries in bed. But what if just the opposite were done? What if the patient was asked to try not to sleep?
This way of acting is what is known as paradoxical intention, in which the patient is required not to try to avoid the problem or what causes him discomfort. Let’s take a closer look at what it consists of.
The paradoxical intention technique is a therapeutic strategy that fundamentally consists of Instruct the patient to continue doing or think about what is causing them discomfort, instead of fighting against it or avoiding it. The origins of this technique are linked to humanistic psychotherapy, specifically to the logotherapy of Viktor Frankl, also having a relationship with the Brief Therapy techniques of the psychiatrist Milton H. Erickson, although the technique has prospered within the cognitive approach.
The name of paradoxical intention is not coincidental. It consists of making the patient do exactly what he wants to solve, and why he comes to the consultation. The patient, who has tried on his own to get rid of her problem, now has to enhance it, exaggerate it and keep it in mind in the here and now. He is encouraged to do or wish to happen that which he precisely fears or avoids. It is clear that this idea confronts the patient’s common sense.
This technique has proven to be one of the fastest and most powerful methods to change patients’ behavior, at the same time also misunderstood. Through a series of “paradoxical” instructions, significant successes are achieved in all types of psychological disorders and problems. Among the applications of paradoxical intention we have patients with problems of insomnia, onychophagia (nail biting), dysphemia (stuttering) and enuresis among others.
For example, if the patient comes to the consultation because he has problems sleeping, when the paradoxical intention is applied, he will be asked to do precisely what causes him discomfort. In this case, instead of trying to get him to sleep, what will be done is ask him to make an effort not to sleep. Ironically, the patient will be investing a lot of effort in avoiding falling asleep, which is exhausting and can have precisely that effect, sleeping.
It is not surprising that the patient is surprised when his therapist tells him to do everything possible to “increase” his main problem. This paradoxical intention collides in the patient’s mind with his expectations about what the therapy was going to be like, especially assuming that it was going to be very clearly focused on doing what would counteract the effects or problems it already suffers from. It is a technique that, at first, may even seem irresponsible on the part of the therapist, contrary to common sense and that may remind us of the popular idea of “reverse psychology.”
The principle of this technique is to make patients try to carry out the behavior or thought that causes them discomfort Before going to the consultation, the patient has most likely tried to solve the problem on his own, so this therapy appears to be the opposite of everything the patient has already done. If the obvious and logical has not fixed anything, it is time to use what is not so obvious.
For example, a patient who suffers from insomnia problems has quite likely already tried to do everything possible to fall asleep, such as stopping caffeine, sleeping earlier, meditating before bed, calming down, playing background music, and other options. When you have decided to go to a consultation, it is most likely that your therapist has applied techniques to improve your sleep, without much success.
All this makes the patient feel more frustrated, and tries all the previous alternatives with more force This increases their anticipatory anxiety, which in this case arises from the fear of not being able to fall asleep, not resting well enough, and not performing in other aspects of their life. This is a very strong circle of thought, from which the patient cannot free himself and which generates even more discomfort.
When told that just the opposite is going to be done, in this case asking him not to sleep, the patient is surprised. He did not expect this and, since the guideline is exactly the opposite of what he wants to achieve, he breaks the vicious circle of frustration for not being able to sleep. Now his task is to try to avoid sleeping, to stay awake as much as possible. It goes from not being able to sleep and causing you discomfort to deciding not to sleep, giving you a greater sense of control. He can’t control when he falls asleep, but he can control staying awake, or so he thinks.
How is the technique applied?
As we have mentioned, the main idea of this technique is require patients to stop the tendency to treat, avoid, or control their symptoms They are asked just the opposite of what they would rationally think they should do. Patients cannot control their symptoms so that they disappear, but they can so that they appear and become more aware.
Two requirements are required to be able to apply the procedure On the one hand, the patient must give up attempts to control the symptom, since he cannot make them disappear. On the other hand, he must be willing to make symptoms appear and increase, something that is not always possible, depending on how unpleasant they are and how supportive the patient is of this unorthodox therapeutic option.
As we have commented, both requirements go against the therapeutic logic that the patient surely manages. It is for this reason that it must be explained, in an extensive and convincing manner, How short-term strengthening of the unwanted behavior/thought can lead to an improvement in the problem
Application sequence
The application of paradoxical intention is applied normally following the following sequence.
1. Problem assessment
First, the problem is evaluated and the logic that keeps the person in ineffective solutions is identified
Taking the case of the person who suffers from insomnia as an example, it would be all the strategies that he has tried on his own and in a therapeutic context (not drinking coffee, going to sleep earlier, meditating, taking sleeping pills…)
2. Redefine the symptom
Once this is done, the symptom is redefined based on the data obtained in the evaluation of the problem. For it It is about providing a new meaning to the symptom for example, indicating advantages if you have them or what it could mean in your life.
In the case of insomnia, it can be said that it is a sign that you are worried or that you believe you have something pending to solve.
3. Apply paradoxical changes
Paradoxical changes are indicated depending on the complaint pattern. In the case of insomnia you would be told to stop sleeping or do everything you can to stay awake, such as doing activities, reading more, watching television.
In the case of onychophagia, you would be told to bite your nails as much as you could during a set period of time in therapy, requiring you not to stop doing so during that period of time.
4. Identification of changes after therapy
Once this is done, changes in the patient’s pattern of behavior or thinking are identified
For example, in the case of insomnia the aim is to find out if the patient has remained awake for several days or if, on the contrary and as a desired effect, he has slept without consciously intending to do so.
In the case of onychophagia, it would be measured how many times the patient has bitten his nails or if he indicates that he has not done so for a few days and had not even realized it.
5. End of the intervention and follow-up
If it is considered that the patient has had an effective and sufficient improvement, the therapy is terminated not without neglecting follow-up to ensure that the patient has indeed had improvements.
Limitations
It should be noted that paradoxical intention is not a miraculous technique, although it has been shown to have great therapeutic capacity. Its benefits as therapy will be achieved as long as it is used creatively having clinical experience and controlling the possible side effects of asking the patient to enhance and exaggerate their discomfort.
The main limitation has to do with the fact that it is an intervention more focused on the patient’s thoughts than on their behavior. Its greatest effectiveness is conditioned by the degree of anxiety of the problem you want to treat. The technique directly affects the patient’s cognitions, since their way of thinking in relation to the original problem is reversed. It goes from not wanting to do X behavior or think about X thing to having to do/think about it, at the therapist’s request.
Another of its limitations is the fact that, at least within current psychotherapy, It is not used as the first psychotherapeutic option Paradoxical intention is considered an unorthodox technique, since requiring the patient to do something that causes discomfort or is part of their psychological problem cannot be considered a fully ethical way of treating, although this depends greatly on the type of problem addressed. in therapy.
For example, in the treatment of insomnia it is relatively harmless to ask the patient to concentrate on not sleeping since, sooner or later, either due to fatigue or unconsciously, they will end up falling asleep. The problem comes with other problems, such as onychophagia and enuresis
In the case of onychophagia, the person would be asked to bite their nails as much as they wanted. In that case, ingesting them could cause damage to both the nails and digestive problems if they never overcome their onychophagia. In the case of childhood enuresis, what is usually done is to tell the child not to worry about wetting the bed at night, that nothing happens. The most likely thing is that sooner or later he will learn not to urinate, having better sphincter control, but what if this technique doesn’t work for him? The child will have been given free rein to wet the bed.
Aspects to consider
Although it is truly useful, This technique can be one of the most difficult procedures to use in cognitive behavioral therapy The therapist must not only know the logic and procedure behind its application, but must also have enough experience to detect when it should be applied.
It is essential that the therapist has very good communication skills and sufficient clinical experience, which will be decisive in the success of the application. The professional must appear confident, firm, with conviction and the ability to simulate, all of them elements that are necessary to gain the patient’s trust and get them to listen to him or her. The patient will be able to question what previously seemed obvious and now you will consider doing exactly what you wanted to avoid as a good option.
