The Paradoxical Approach

Two ideas central to treatment:

1. Focusing on observable behavioural interaction in the present
2. Deliberate intervention to alter the ongoing system

All theories of psychotherapy have limitations of practice as well as conception, inherent in their own nature (although often attributed to human nature).

Basic Premise: the kinds of problems people bring to psychotherapists persist only if they are maintained by ongoing current behaviour of patient & others.
Converse: A change in problem-maintaining behaviour leads to elimination of the problem.

Disturbed, etc. behaviour occurs as one aspect of a system; reflects system dysfunction; best treatment is modification of system. However, it is not necessary to alter the system fundamentally – apparently minor changes in overt behaviour or its verbal labeling often are sufficient to initiate progressive developments. Also, “payoffs” of symptomatic behaviour are not especially significant as causes of problems or obstacles to change.

Based on work of Milton Erickson:
1. Change existing behaviour by implicit or indirect means of influence;
2. “Accept what the client offers” even if it appears as resistance or pathology.

• Avoid promoting “insight”, ie avoid explicit clarification of nature of behaviour.
• Emphasize active intervention aimed at reordering family relationships to achieve rapid problem resolution.
• Assign homework.
• Presenting problem offers: what the patient is ready to work on; a concentrated manifestation of what’s wrong; and a concrete index of any progress made.
• Normal transitional steps in family living are the most common & important “everyday difficulties” that may lead to problems when handled badly. Transitions include marriage, birth of first child, child entering school, death of spouse.

Problems are likely to develop if:
1. An ordinary difficulty is treated as a “problem”
2. A difficulty is treated as no problem at all.

Over or under-emphasis of life difficulties depends on general cultural attitudes, as well as personal/family characteristics. Often, an original difficulty is met with an attempted “solution” that intensifies the difficulty, eg trying to cheer up a depressed patient.

A “chronic” problem is the persistence of a repetitively poorly handled difficulty. This can be changed; the difference between it and an acute problem is often the pessimism of the therapist.

Resolution of problems requires a substitution of behaviour patterns so as to interrupt the positive feedback.
• the remedies may appear illogical, but they work;
• “think small”: focus on symptom presented, work towards its relief;
• a small but definite change may lead to further, self-induced changes.

Brief therapy stages:

1. Introduction to treatment setup
2. Inquiry and definition of problem
3. Estimation of behaviour maintaining problem
4. Setting goals of treatment
5. Selecting and making behavioural interventions
6. Termination.

Tell the patient: a maximum of ten sessions per case; this encourages positive expectations of rapid change.

A. Defining Problem:

“What do you do now because of your problem that you want to stop doing, or do differently?” “What would you like to do that your problem interferes with doing now”?

B. Estimate behaviour maintaining the problem:

Usually what patient and others are doing to deal with the problem. Don’t confront people with their mistake.

C. Setting treatment goals:

“At a minimum, what (change in) behaviour would indicate that a definite step forward has been made in your problem?”

D. Intervention:

• Utilize interpretations to “relabel” behaviour, not for insight – it doesn’t matter if new or old label is truthful.
• Use idiosyncratic characteristics and motivation as potential levers for useful interventions.
• Directed behaviour change: instructions carefully framed and made indirect, implicit, or apparently insignificant; minimize the matter or the manner; suggest, not order, a change.
• Paradoxical instructions: encourage symptomatic or other undesirable behaviours to bring it under control. Stress “going slow”; point out possible disadvantages of improvement (Such warnings reduce anxiety about change). If get rapid changes, prescribe a relapse.
• Utilize interpersonal influence: work with client’s family, friends, work situation.
• Utilize therapist and observers, eg “good guy/bad guy”.

E. Termination:

Occasionally may want to minimize positive treatment outcome and express skepticism re future progress.

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