Paradoxical Psychotherapy

Theory & Practice With Individuals Couples & Families

Gerald R. Weeks, Luciano L'Abate

• Publisher: Routledge
• Year: 2013
• eBook ISBN:
  9781134842452
• Topic: Psicología
• Subtopic: Salud mental en psicología

First published in 1982. Paradoxical psychotherapy has rapidly become one of the most· important approaches to family therapy and psychotherapy during the past few years. The aim of this book is to present an overview of paradoxical therapy. Paradoxical Psychotherapy: Theory and Practice with Individuals, Couples, and Families Is designed for all clinical psychologists. Applications are offered for the individual, marital, and family therapist.

1

Introduction to paradoxical psychotherapy

Paradoxes have fascinated men since the sixth century B.C. when Epimenides of Megara devised the paradox of the liar, and Zeno of Elea formulated the paradoxes of infinity (Hughes and Brecht, 1975). Epimenides’ mind-boggling liar paradox asserted that “all Cretans are liars.” However, since Epimenides was also from Crete, then he too must be a liar. But if Epimenides is a liar, then the statement, “all Cretan are liars,” must be a lie, which means that all Cretans tell the truth … except Epimenides was just proved to be lying … but since he is from Crete … ad infinitum. Interest in paradox waned following Zeno until the late nineteenth century revival of logic (Edwards, 1967). Recently, family therapists have developed an intense interest in a special type of paradox, leaving logical and semantic paradoxes to the domain of philosophers and linguists (Soper and L’Abate, 1977).

The purpose of this book is to examine the various ways in which the paradox may be applied in psychotherapy. While it is important to understand theory, the major emphasis of this book will be on how to use or apply paradoxical methods. Paradoxical psychotherapy is a relatively new, exciting, powerful, and non-commonsensical form of therapy. Its most outstanding characteristic is its departure from traditional psychotherapeutic techniques. Few therapists have been willing or able to practice paradoxical psychotherapy due to its uniqueness and the lack of any coherent guide. In fact, it could be stated from the outset that the guiding principle of a paradoxical therapist is: “If a therapist would do it, do the opposite.” This principle is itself paradoxical, referring to traditionally trained therapists. Paradoxical methods have been used primarily by family or systems-oriented therapists. Haley (1963, 1976), Selvini Palazzoli and her group (1978a), and Watzlawick et al. (1967, 1974) are probably the best-known proponents of the paradoxical treatment of families. In addition, a review of the literature shows that the majority of articles published on paradoxical techniques have appeared in the family therapy journal Family Process (Weeks and L’Abate, 1978). This book will demonstrate how the paradox can be applied in individual, marital, and family therapy, with more emphasis on the latter two forms of therapy.

WHAT IS PARADOXICAL PSYCHOTHERAPY?

Logicians have distinguished three types of paradoxes (Watzlawick, Beavin, and Jackson, 1967). The first type is the antinomy. These paradoxes are statements which are contradictory but provable. In other words, they are logical contradictions and are of interest only to logicians and mathematicians. The second type of paradox is the semantic antinomy or paradoxical definition. Faradoxical definitions stem from hidden inconsistencies in the structure of our language. Epimenides’ liar paradox is an example of a paradoxical definition. Bertrand Russell’s theory of logical types also illustrated a paradoxical definition in that whatever comprised all of a collection cannot be one of the collection. In order to prevent these types of paradoxes from occurring, logical levels must be kept separate, and it must be recognized that going from one level to the next involves a quantum jump in a system.

The third type of paradox is the most important because it underlies paradoxical psychotherapy. This paradox is called the pragmatic paradox. Unlike a contradiction, a pragmatic paradox gives a person no choice. “Thus, if the message is an injunction, it must be disobeyed to be obeyed; if it is a definition of self or other, the person thereby defined is this kind of person only if he is not, and is not if he is” (Andolfi, 1974, p. 222). Accordingly, paradoxical therapy is based on the principle that a person is expected to change by remaining unchanged. The classic example of this principle and of the pragmatic paradox is the paradoxical injunction, “Be spontaneous.” As soon as one attempts to act on this command, one cannot. It is only when one gives up that one can behave spontaneously. The most common form of the pragmatic paradox or therapeutic paradox is to prescribe the symptom—in other words, to encourage the client to become even more symptomatic.

The earliest research on the pragmatic paradox was conducted by the Palo Alto group (the Bateson project and the Mental Research Institute). In 1956, Gregory Bateson, Don Jackson, Jay Haley, and John Weakland published a classic paper called, “Toward a theory of schizophrenia.” This paper pointed out the pathological aspects of paradoxical communication in producing schizophrenia and suggested that pragmatic paradoxes could be used therapeutically. At the time this paper was published, the term pragmatic paradox was not being used. Instead, the equivalent term “double-bind” was being used. The development of this work eventually revealed that a therapeutic double-bind is a mirror usage of a pathological double-bind (Watzlawick et al., 1967).

To understand a therapeutic double-bind fully, it is essential first to examine a pathogenic double-bind. In a pathogenic double-bind, a person is placed in a no-win situation. Bateson et al. (1956) asserted that repeated exposure to this kind of communication could produce schizophrenia. More recently, Sluzki and Eliseo (1971) have considered the double-bind a universal pathogenic situation accounting for neurotic as well as psychotic symptomatology.

For double-binding to take place, several conditions must be met over a period of time. The first requirement is that there be two or more persons who are closely connected (e.g., family members). Secondly, there must be communication around some recurrent theme. A single experience is not deemed effective. Thirdly, a primary negative injunction must occur. This verbal injunction usually occurs in two forms: a) “Do not do so and so, or I will punish you,” or b) “If you do not do so and so, I will punish you.” The learning context is one of avoidance of punishment. Fourthly, a secondary injunction is delivered which conflicts with the first and also threatens punishment. The secondary message is generally more difficult to grasp, recognize, or articulate because it is usually conveyed nonverbally. The classic example is a mother tightening up and folding her arms as she says, “I love you” to her child. Finally, a tertiary negative injunction is communicated which prohibits the victim of the bind from leaving the field or commenting on his/her untenable situation.

While a pathogenic double-bind places a person in a no-win predicament, a therapeutic double-bind forces a client into a no-lose situation. In the therapeutic double-bind, there is also some kind of intense relationship over a period of time. Within the context of therapy, the behavior the client wants to change or eliminate is prescribed or encouraged by the therapist, and the therapist implies that this reinforcement is the means of change. The client is placed in the double-bind of being told to change by staying the same. Watzlawick et al. (1967) stated, “If he complies, he no longer ‘can’t help it’; he does ‘it,’ and this, as we have tried to show, makes ‘it’ impossible, which is the purpose of therapy. If he resists the injunction, he can do so only by not behaving symptomatically, which is the purpose of therapy” (p. 241).

Finally, the client is not permitted to dissolve the paradox by commenting on it. In other words, in a therapeutic double-bind, a client gains control over the symptom by either giving it up (disobeying the injunction) or by enacting it intentionally or voluntarily. If the latter occurs, the client has gained control over the symptom in the sense that s/he now controls it, and not vice versa. This type of bind or paradoxical situation forces the client outside his or her pathological frame of reference.

Pragmatic paradoxes or therapeutic double-binds produce a unique kind of change. Watzlawick et al. (1974) maintained that paradoxical injunctions produce second-order rather than first-order change. First-order change refers to change within a particular frame of reference or system, such as the events which happen or change within dreams. Second-order change refers to a change in the frame of reference or system itself, such as a change from dreaming to waking. Second-order change is actually the process which allows the client to escape from the pathogenic double-bind. The solution is the new frame created by the client’s escape from the bind. The therapeutic double-bind implicitly challenges the client’s model of the world by forcing him/her into an experience which contradicts the self-destructive limitations of the present model. This experience serves as a reference structure by which the client expands his model of the world (Bandler and Grinder, 1975, p. 169).

HISTORY OF PARADOXICAL PSYCHOTHERAPY

The history of paradoxical psychotherapy proper begins with the work of the Palo Alto and Mental Research Institute group and was later formalized in Pragmatics of Human Communication by Watzlawick, Beavin, and Jackson in 1967. However, it is a mistake to believe that paradoxical techniques suddenly came into existence with this group. Paradoxical techniques have been used since the early days of psychotherapy. These techniques are embedded in many different systems of psychotherapy which are rarely credited today with having any impact on the development of paradoxical psychotherapy. Even more interesting is the fact that each system which employs paradoxical techniques provides a different theoretical explanation about why these techniques work. A comparative historical analysis of paradox helps us understand what has been tried and why these techniques have been effective.

According to Mozdzierz, Macchitelli, and Lisiecki (1976), Alfred Adler (1914) was the first person in Western civilization to use and write about paradoxical strategies. Mozdzierz et al. (1976) pointed out that paradox is dialectics applied to psychotherapy. Adler was strongly influenced by the work of Nietzsche, Vaihinger, and Hegel and believed dialectical thinking to be the modus operandi of his psychology (Ansbacher, 1972).

Mozdzierz et al. (1976) delineated what they call Adler’s (1956) nonspecific paradoxical strategy and identified 12 specific paradoxical techniques which they claim stem from Adlerian psychology. Adler’s (1956, p. 337) nonspecific paradoxical strategy was to avoid power struggles with clients. He stated that clients will attempt to depreciate the therapist by doing things such as expressing doubt, criticizing, forgetting, being late, making special requests, and having relapses. Adler viewed neurotic symptoms as teleologically uncooperative symptoms, or inadequate ways of dealing with the demands of life, especially social cooperation or social interest. The use of paradoxical strategies shifts the patient’s symptomatic uncooperative behavior to cooperative behavior between the therapist and client. Adler advised the therapist of the ways to “never force a patient,” such as renouncing his/her own superiority, being constantly friendly, keeping a cool head, and never fighting with a client. In other words, he suggested going with or accepting the patient’s resistance. The following case illustrates this idea.

A girl of 27 who came to consult me after five years of suffering said: “I have seen so many doctors that you are my last hope in life.” “No,” I answered, “Not the last hope. Perhaps the last but one. There may be others who can help you too.” Her words were a challenge to me; she was daring me not to cure her, so as to make me feel bound in duty to do so. This is the type of patient who wishes to shift responsibility upon others, a common development of pampered children. It is important to evade such a challenge. The patient may have worked up a high tension of feelings about the idea that the doctor is his “last hope,” but we must accept no such distinction. To do so would be to prepare the way for a disappointment, or even suicide (Adler, 1956, p. 339).

It is also interesting to note that Adler (1956) was the first theorist to deal with depression paradoxically. He recognized the interpersonal dynamics of depression and used a paradoxical technique which is today called restraining. He would instruct the depressed patient to:

“Never do anything you don’t like.” This seems to be a very modest request, but I believe it goes to the root of the whole trouble. If a depressed person is able to do anything he wants whom can he accuse? What has he got to revenge himself for? “If you want to go to the theatre,” I tell him, “or to go on a holiday, do it. If you find on the way that you don’t want to, stop it.” It is the best situation anyone could be in. It gives a satisfaction to his striving for superiority. He is like God and can do what he pleases. On the other hand, it does not fit very easily into his style of life. He wants to dominate and accuse others; if they agree with him, there is no way of dominating them.… Generally the patient replies, “But there is nothing I like doing.” I have prepared for this answer, because I have heard it so often. “Then refrain from doing anything you dislike,” I say.… I know that if I allow it, he will no longer want to do it. I know that if I hinder him, he will start a war (Adler, 1956, p. 346–347).

Some of the specific Adlerian-based techniques Mozdzierz et al. (1976) described are: 1) permission—giving the client permission to have a symptom; 2) prediction—predicting the client’s symptoms would return, or that he would have a relapse; 3) proportionality—getting the client to exaggerate symptoms or have the therapist take them more seriously than the client; 4) pro-social redefinition—redefining or reinterpreting symptomatic behavior in a positive instead of negative way; 5) prescription—directing the client to engage in his symptomatic behavior; and 6) practice—asking the client to refine and improve his symptomatic behavior.

The second theorist to explore the technique of symptom prescription was probably Knight Dunlap in 1928 (Watzlawick et al., 1967; Raskin and Klein, 1976). Dunlap (1928, 1930) developed a procedure he called “negative practice” for such symptoms as nail biting, enuresis, and stuttering. He would direct the client to practice the symptom under prescribed conditions with the expectation of losing the habit. Dunlap (1946) never developed an adequate rationale for the technique of negative practice. However, his description of negative practice is very similar to the present-day concept of paradox and offers an implicit theoretical basis. Dunlap (1946) stated: “The general principle of negative practice is that of making an effort to do the things that one has been making an effort not to do, instead of making an effort to avoid doing the things that one has been doing.… The principle involved might be formulated as bringing under voluntary control responses which have been involuntary.… This is merely a description of the results of negative practice and is not an explanation” (p. 194).

Dunlap changed his original views toward the application and effectiveness of this technique in his later work. In his early work he believed the technique could be used to treat a variety of disorders, but by 1932 he believed it would only be applicable to small motor habits.

The principle of negative practice is often called “massed practice” by modern behavior theorists. Hull (1943) provided a theoretical explanation of massed practice with his construct of “reactive inhibition.” He stated that the repetition of a behavior in rapid succession was aversive to an organism, and the rest period which follows is pleasurable or negatively reinforcing. The fatigue plus the negative reinforcement become paired with not performing the symptom and inhibit its further occurrence. A review by Rimm and Masters (1974) of the research on negative practice showed the technique produces mixed outcome.

There are two other more recent behavioral techniques which can be construed as paradoxical. One well-known technique is implosion. Implosive therapy attempts to eliminate avoidance behavior through the process of extinction. It is commonly used to treat phobias but has been applied to such problems as sexual deviations, loss of impulse control, guilt, aggression, and fear of rejection. Implosive therapy requires the client to imagine the scenes of the avoided behavior from least to most anxiety-provoking without being permitted actually to engage in any avoidance behavior. For example, an individual who feels hostile and angry toward someone might be told to imagine verbalizing those thoughts and culminate in imagining that he is a wild animal ripping his victim apart. Stampfl and Levis (1967) presented the first complete description of implosion, and the technique has been shown to produce mixed outcome (Rimm and Masters, 1974).

Stimulus satiation is the most recent behavioral technique related to paradoxical psychotherapy. This technique involves repeated exposure of the desired stimulus to the client. The best known case was reported by Ayllon (1963). A psychotic patient had developed the habit of hoarding towels. The staff was instructed to give her more and more towels over five weeks. By the sixth week the patient was not only refusing more towels but removing them from her room.

Of all the historical percursors of paradoxical psychotherapy, Victor Frankl’s work is the most explicitly paradoxical. Frankl developed an existential approach to psychotherapy which he called logotherapy. The goal of logotherapy was to make man consciously accept personal responsibility. One of the main techniques of logotherapy is paradoxical intention. Frankl (1975) claimed he was using paradoxical intention as early as 1925, but he did not formally describe it until 1939 (Frankl, 1939). The first major English presentation of his work appeared in 1965 in a book entitled, The Doctor and the Soul: From Psychotherapy to Logotherapy. Paradoxical intention involves directing the patient intentionally to will the symptom to occur. Frankl (1967) stated:

The reader will note that this treatment consists not only of a reversal of the patient’s attitude toward his phobia inasmuch as the usual “avoidance” response is replaced by an intentional effort—but also that it is carried out in as humorous a setting as possible. This brings about a change of attitude toward the symptom which enables the patient to place himself at a distance from the symptom, to detach himself from his neurosis. This procedure is based on the fact that, according to the logo-therapeutic teaching, the pathogenesis in phobias and obsessive-compulsive neurosis is partially due to the increase of anxiety and compulsions by the endeavor to avoid or fight them. A phobic person usually tries to avoid the situation in which his anxiety arises, while the obsessive-compulsive tries to suppress, and thus fight, his threatening ideas. In either case the result is a strengthening of the symptom. Conversely, if we succeed in bringing the patient to the point where he ceases to flee from or to fight his symptoms, but on the contrary, even exaggerates them, then we may observe that the symptoms diminish, and that the patient is no longer haunted by them (pp. 146–147).

Paradoxical intention was based on the principle that anxiety neurosis and phobic reactions are characterized by anticipatory anxiety. Moreover, it is anticipatory anxiety which produces the conditions the patient fears. Paradoxical intention is designed to interrupt the vicious cycle by reducing or eliminating the anticipatory anxiety, hence the neurotic condition. Frankl emphasized that he was not merely treating the symptom but was changing the patient’s attitude toward his neurosis. He called this change in attitude an existential reorientation. He also stated that humor was an essential ingredient in the patient’s being able to detach himself from his neurotic condition. In many of his cases the patient begins laughing at himself as soon as he is instructed to will the symptom. One of Frankl’s (1967) frequently cited cases illustrates these principles:

A young physician came to our clinic becaus...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Contents
• Foreword
• Preface
• Acknowledgments
• 1. Introduction to Paradoxical Psychotherapy
• 2. Human Nature and the Paradoxical Theory of Change
• 3. The Dialectics of Psychopathology
• 4. When to Work Paradoxically
• 5. How to Work Paradoxically
• 6. Organizing Paradoxical Techniques
• 7. A Compilation of Paradoxical Techniques
• 8. Recent Innovations in the Use of Paradoxical Techniques
• 9. Paradoxical Letters
• 10. Case Studies in Paradoxical Psychotherapy
• 11. Research
• 12. Professional and Ethical Issues
• References
• Index