Paradoxical intention: what is it and how is this technique used in psychotherapy?

A summary about the characteristics of the psychotherapy technique called paradoxical intention.

When the patient goes to consultation, the therapist is expected to apply all kinds of techniques focused on reducing, in a very direct and clear way, any symptomatology that causes him/her discomfort.

One expects that if you suffer, for example, from insomnia, the psychologist will treat you with some kind of relaxation and dynamics to avoid worries in bed. But what if the opposite were done? What if the patient were asked to try not to sleep?

This way of acting is known as paradoxical intentionin which the patient is required not to try to avoid the problem or the thing that is causing him/her discomfort. Let us see more in depth in what it consists.

What is the paradoxical intention technique?

The technique of paradoxical intention is a therapeutic strategy that consists, fundamentally, of to indicate to the patient to continue doing or thinking about what is causing him/her discomfort, instead of fighting or avoiding it.instead of fighting or avoiding it. The origins of this technique are linked to humanistic psychotherapy, specifically to Viktor Frankl's logotherapy, and it is also related to the Brief Therapy techniques of the psychiatrist Milton H. Erickson, although the technique has flourished within the cognitive approach.

The name of paradoxical intention is not accidental. It consists in 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 his 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 that what he fears or avoids will happen. It is clear that this idea confronts the patient's common sense.

This technique has proved to be one of the quickest and most powerful methods for changing the behavior of patientsand at the same time 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 insomnia, onychophagia (nail biting), dysphemia (stuttering) and enuresis among others.

For example, if the patient comes for consultation because he/she has trouble sleeping, when the paradoxical intention is applied, he/she will be asked to do precisely that which causes him/her discomfort. In this case, instead of treating him to make him fall asleep, what will be done is to ask him to make an effort not to sleep. Ironically, the patient will be expending a lot of effort to avoid falling asleep, which is exhausting and can have the effect of just that, sleep.

No wonder the patient is surprised when his therapist tells him to do everything possible to "augment" his main problem. This paradoxical intention clashes in the patient's mind with his expectations about how the therapy was going to be, especially assuming that it was going to be a "good" therapy.This paradoxical intention clashes in the patient's mind with his expectations of what the therapy would be like, especially assuming that it would be very clearly focused on doing what would counteract the effects or problems he already suffers from. It is a technique that, at first glance, may seem irresponsible on the part of the therapist, contrary to common sense and reminiscent of the popular idea of "reverse psychology".

How does it work in therapy?

The principle of this technique is to to make patients try to carry out the behavior or thought that causes them discomfort.. Before going for consultation, the patient has most likely tried to solve the problem on his or her own, so this therapy is shown to be the opposite way to anything 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 suffering from insomnia problems is quite likely to have already tried everything possible to fall asleep, such as stopping caffeine, going to sleep earlier, meditating before bedtime, calming down, playing background music, and other options. By the time you have decided to go for a consultation, your therapist will most likely have applied techniques to improve your sleep, without much success.

All this makes the patient feel more frustrated, and he will try all the above alternatives harder.. This increases his anticipatory anxiety, which arises in this case from the fear of not being able to sleep, not resting well enough and not performing in other aspects of his life. This is a very strong circle of thinking, from which the patient is unable to free himself and which generates even more discomfort.

When you tell him that you are going to do just the opposite, in this case ask him not to go to sleep, the patient is surprised. He did not expect this and, as the directive is just the opposite of what he wishes to achieve, the vicious circle of frustration at not being able to sleep is broken. Now your task is to try to avoid sleeping, to stay awake as much as possible. He goes from not being able to sleep and causing him discomfort to deciding not to sleep, giving him 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 already mentioned, the main idea of this technique is to require patients to stop the tendency to treat, avoid or control their symptoms.. They are asked to do just the opposite of what they would rationally think they should do. Patients cannot control their symptoms so that they disappear, but they can control their symptoms so that they appear and become more aware.

Two requirements are necessary to be able to apply the procedure. On the one hand, the patient must give up attempts to control the symptom, inasmuch as he cannot make them disappear. On the other hand, he or she must be willing to make the symptoms appear and increase, which is not always possible, depending on how unpleasant the symptoms are and how much the patient favors this unorthodox therapeutic option.

As we have already mentioned, both requirements go against the therapeutic logic that the patient is likely to handle. It is for this reason that it should be explained, extensively and convincingly, how the short-term enhancement of the undesired behavior/thought can lead to an improvement of the problem..

Sequence of application

The application of the paradoxical intention is usually applied following the following sequence.

1. Assessment of the problem

First, the problem is evaluated and the logic that keeps the person in ineffective solutions is identified..

Taking as an example the case of the person suffering from insomnia, this would involve all the strategies he/she has tried on his/her own and in a therapeutic context (not drinking coffee, going to sleep earlier, meditating, taking sleeping pills...).

2. Redefining the symptom

Once this has been done, the symptom is redefined according to the data obtained in the evaluation of the problem. In order to do this it is a question of bringing a new meaning to the symptomFor example, indicating advantages if you have them or what it could mean in your life.

In the case of insomnia, you can talk about it as a sign that you are worried or that you think you have something pending to solve.

3. Apply paradoxical changes

Paradoxical changes are indicated according to the complaint pattern. In the case of insomnia, the patient would be told to stop sleeping or to do everything possible to stay awake, such as doing activities, reading more, watching TV.

In the case of onychophagia, he would be told to bite his nails as much as he could for a period of time established in therapy, requiring him not to stop doing so during that time.

4. Identification of changes after therapy

Once this is done, changes in the patient's behavior or thought pattern are identified..

For example, in the case of insomnia, the aim is to find out whether the patient has been awake for several days or whether, on the contrary and as a desired effect, he or she has slept without consciously intending to do so.

In the case of onychophagia, we would measure how many times the patient has bitten his nails or whether he indicates that he has not done so for several days and has not even noticed.

5. End of the intervention and follow-up

If it is considered that the patient has had an effective and sufficient improvement, we proceed to end the therapy, but not without neglecting the follow-up to check the patient's condition.If it is considered that the patient has had an effective and sufficient improvement, the therapy is terminated, but not without neglecting the 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 a great therapeutic capacity. Its benefits as a therapy will be achieved as long as it is used creatively.The main limitation has to do with the fact that it is an intervention more focused on the patient's thinking than on his or her behavior.

The main limitation has to do with the fact that it is an intervention more focused on the patient's thinking than on his behavior. Its greater effectiveness is conditioned by the degree of anxiety of the problem to be treated. The technique has a direct impact on the patient's cognitions, since it reverses his or her way of thinking in relation to the original problem. The patient goes from not wanting to do X behavior or think about X thing to having to do/think about it, as demanded by the therapist.

Another of its limitations is the fact that, at least within current psychotherapy, it is not used as the first psychotherapy option, 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 him/her discomfort or is part of his/her psychological problem cannot be considered a fully ethical way of treating, although this depends very much 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 from tiredness or unconsciously, he or she will fall asleep. The problem comes with other problems, such as onychophagia and enuresis..

In the case of onychophagia, the person would be asked to bite his or her nails as much as he or she wants. In that case, damage to the nails and digestive problems could be caused by ingesting them in case he/she never overcomes his/her onychophagia. In the case of child bedwetting, what is usually done is to tell the child that during the night not to worry about wetting the bed, that nothing happens. Sooner or later the child will most likely learn not to wet the bed, having a better sphincter control, but what if this technique does not work? The child will have been given free rein to wet the bed.

Aspects to keep in mind

Although it is really useful, this technique can be one of the most 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 be experienced enough to detect when it should be applied.

It is essential that the therapist possesses 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 simulation skills, all of which are necessary to gain the patient's confidence and make him/her listen to him/her. The patient will be able to question what seemed obvious to him/her before and will now consider it a good option to do the very thing that and will now consider as a good option to do just what he wanted to avoid.

Bibliographic references

• Azrin, N. H. and Gregory, N. R. (1987). Treatment of nervous habits. Barcelona, Martínez Roca.
• Bellack, L. (2000). Guía de preguntas del manual de psicoterapia breve, intensiva y de urgencia; tr por Ma. Celia Ruiz de Chávez. (1st Ed., 6th. Reimp.) Mexico: Ed. El Manual Moderno.