Academic journal article The Israel Journal of Psychiatry and Related Sciences

Dynamic Perspectives of Paradoxical Intervention

Academic journal article The Israel Journal of Psychiatry and Related Sciences

Dynamic Perspectives of Paradoxical Intervention

Article excerpt

Abstract: This paper describes the use of paradoxical intervention with a patient who, despite his persistent appeals for help, remained uncooperative. It endeavors to show an understanding of the patient's destructiveness as an expression of his neediness and envy, which he expresses via his repeated use of projective identification and suggests this intervention as a way out. From a dynamic perspective the paradoxical intervention encompasses two contrasting aspects: On the one hand, it rechannels the patient's destructiveness and envy in a beneficial direction. In that sense the intervention fulfills the patient's wish for an omnipotent therapist and for painless therapy, while appearing to prevent personality change. On the other hand, the intervention interferes with the continued use of projective identification, it facilitates the expression of non-destructive aggression, creates an ambiguity surrounding the question of who is in fact in control of the therapy and, finally, it possibly facilitates the creation of a potential space. In that sense the paradoxical intervention assists in achieving both the experience of separateness and the ability to use symbolization. Parallel processes are described in the therapist's countertransference.


Paradoxical intervention is a form of therapeutic intervention wherein the therapist makes an apparently illogical suggestion to the patient. He may propose that the patient conduct himself in such a way as to aggravate the symptoms or demonstrate them in anxiety-provoking circumstances (1). Paradoxical intervention as a distinct therapeutic approach was introduced relatively late in the development of psychotherapy. It is employed in a wide array of therapeutic situations with considerable efficacy (2). Naming it as paradoxical may reflect only our lack of understanding of the mechanisms underlying its curative effects (3). It may be noted that the potentially powerful effects of the pardoxical intervention demand of the therapist to apply good clinical judgement and technical skill.

Its use and theoretical conceptualization are mainly in the framework of non-analytic oriented psychotherapies. Behavioral therapists explain the effect of the intervention in the development of a conditioned inhibition, which refers to the notion that constant repetition leads to extinction even when rewarded, or to satiation which refers to decreased effectiveness of a repetitive reward. Haley (4) talks of the paradoxical double-bind message sent by the patient's requests both for an improvement of his situation as well as resistence to change. The paradoxical intervention creates a therapeutic counterparadox in which the patient must choose between either submitting to the therapist who is recommending symptomatic aggravation or resisting him through a symptomatic amelioration. Watzlawick et al.

(1) claim that the patients' attempts to cope with their symptoms are often part of a vicious circle which preserves the problem. Therefore, the solution may well lie in an attempt to cut off this circle through a change in the patient's conceptualization of his/her problem and the manner in which he/she will cope. Since such maneuvers are often incompatible with conventional, commonsense views, they are therefore considered unexpected and surprising. Omer (5) believes that the patient's symptoms are significant only in a well-defined context. He suggests that the paradoxical intervention empties that context of its significance in the eyes of the patient and renders the symptom meaningless.

All the above mentioned explanations hardly refer to the emotional reverberations or unconscious meaning of the paradox. A broad consensus exists that a good therapeutic relationship is crucial, while the patient's understanding of the paradox, just as his/her conscious cooperation or rather lack of it are relatively unimportant (4, 5, 6). All these characterizations suggest that unconscious, transferential issues are of great import in the effectiveness of paradoxical intervention, although scarcely addressed. …

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