Paradoxical intention: what is and how is this technique used in therapy

When the patient goes to the consultation, the therapist is expected to apply all kinds of techniques focused on reducing, in a very direct and clear way, all symptoms that cause discomfort.

One hopes that if he suffers, for example, insomnia, the psychologist will treat him through some kind of relaxation and dynamics to avoid worries in bed. But what if the opposite was 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 that which causes discomfort. Let's take a closer look at what it is.

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What is the paradoxical intention technique like?

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

The name of the paradoxical intention is not accidental. It consists of making the patient do exactly what he wants to solve, and for what he comes to consult. The patient, who has tried on his own to get rid of her problem, now has to enhance it, exaggerate it and keep it well present in the here and now. He is encouraged to do or wish to happen precisely what he fears or avoids. It is clear that this idea confronts the common sense of the patient.

This technique has proven to be one of the fastest and most powerful methods to change the behavior of patients, while also misunderstood. Through a series of "paradoxical" instructions, significant successes are achieved in all kinds 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 for consultation because he has trouble sleeping, when 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 asking 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 just that effect, sleep.

It is not surprising that the patient is surprised when his therapist tells him to do everything possible to "increase" her main problem. This paradoxical intention collides in the patient's mind with his expectations about how the therapy was going to be., especially assuming that it was going to be very clearly focused on doing what would counteract the effects or problems that it already suffers. It is a technique that, at first, may even seem irresponsible on the part of the therapist, contrary to common sense, and which may recall the popular idea of ​​"reverse psychology."

How does it work in therapy?

The principle of this technique is to make patients try to carry out the behavior or thought that causes them discomfort. Before going to consultation, the patient most likely tried to solve the problem on his own. own account, so this therapy is shown as the opposite way to everything that the patient has already done. If the obvious and logical hasn't fixed anything, it's time to use the less obvious.

For example, a patient suffering from insomnia problems is quite likely to have already tried to do everything possible to falling asleep, such as stopping caffeine, sleeping sooner, meditating before bed, calming down, playing background music, and more options. By the time you've decided to go for a consultation, your therapist has most likely applied techniques to improve your sleep, without much success.

All this makes the patient feel more frustrated, and that he tries all the previous alternatives with more force. This increases his anticipatory anxiety, which arises in this case from the fear of not being able to fall asleep, not resting well enough, and not performing in other aspects of his life. This is a very strong circle of thought, from which the patient cannot break free and which causes him even more discomfort.

By telling him that the opposite is going to be done, in this case asking him not to sleep, the patient is surprised. This was not expected and, as the guideline is just the opposite of what you want to achieve, the vicious cycle 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. Go from not being able to sleep and causing you discomfort to deciding not to sleep, giving you a greater sense of control. You can't control when you sleep, but you can control staying awake, or so you think.

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How is the technique applied?

As we have commented, the main idea of ​​this technique is requiring patients to stop the tendency to treat, evade, or control their symptoms. They are being 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 control them 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 renounce attempts to control the symptom, while he cannot make them disappear. On the other hand, he must be willing to make the symptoms appear and increase, something that is not always possible, in depending on how unpleasant these are and how supportive the patient is of this therapeutic option so little orthodox.

As we have commented, both requirements go against the therapeutic logic that the patient will surely handle. It is for this reason that it should be explained, in an extensive and convincing way, how enhancing unwanted behavior / thinking in the short term can improve 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 as an example the case of the person who suffers insomnia, it would be all the strategies that he has Tried on its own and in therapeutic context (no coffee, go to sleep earlier, meditate, drink 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 of the symptom, for example, indicating benefits in case he has them or what it could mean in his life.

In the case of insomnia, it can be said that it is a sign that he is worried or that he thinks he has something pending to solve.

3. Apply paradoxical changes

Paradoxical changes are indicated based on the pattern of complaint. In the case of insomnia, you would be instructed to stop sleeping or to do everything possible to stay awake, such as doing activities, reading more, watching television.

In the case of onychophagia he would be told to bite his nails as much as he could during a set period of time in therapy, demanding that he not stop during that period of time.

4. Identification of changes after therapy

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

For example, in the case of insomnia it is a question of finding out if the patient has stayed awake several days or if, on the contrary and as a desired effect, you have slept without conscious intention of it.

In the case of onychophagia, it would be measured how many times the patient has chewed on his nails or if he indicates that he has not done it for a few days and had not even realized it.

5. End of 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 the follow-up to make sure 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, having clinical experience and controlling the possible collateral effects of asking the patient to enhance and exaggerate her discomfort.

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

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 as a fully ethical way of treating, although this depends a lot on the type of problem addressed in therapy.

For example, in the treatment of insomnia it is relatively harmless to ask the patient to focus on not sleeping since, sooner or later, either from tiredness or unconsciously it will end sleeping. The problem comes with other problems, such as onychophagia and enuresis.

In the case of onychophagia, the person would be asked to bite his nails as much as he wanted. In that case, it could cause damage to both the nails and digestive problems when ingesting them in case you never get over your onychophagia. In the case of infantile enuresis, what is usually done is to tell the child not to worry about wetting the bed at night, that nothing happens. The safest thing is that sooner or later you will learn not to urinate, having better control of the sphincters, but what if this technique does not work for you? 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 be confident, firm, with conviction and the ability to simulate, all of which are necessary to gain the patient's trust and to pay attention to him. The patient will be able to question what seemed obvious before And now he will consider doing just what he wanted to avoid as a good option.

Bibliographic references

• Azrin, N. H. and Gregory, N. R. (1987). Treatment of nervous habits. Barcelona, ​​Martínez Roca.
• Bellack, L. (2000). Brief, intensive and emergency psychotherapy manual question guide; tr by Ma. Celia Ruiz de Chávez. (1st Ed., 6th. Reimp) Mexico: Ed. The Modern Manual.