Fam Proc 20:25-35, 1981

Types of Paradoxical Intervention and Indications/Contraindications forUse in Clinical Practice

LAWRENCE FISHER, PH.D.a

ANN ANDERSON, M.S.W.b

JAMES E. JONES, PH.D.b

aUniversity of California, San Francisco; Fresno Central San Joaquin Valley Medical Education Program; and Veterans AdministrationHospital, Fresno, Calif.bDepartment of Psychiatry, University of Rochester Medical School, Rochester, New York.

A review of theoretical mechanisms underlying paradoxical interventions is undertaken in an effort to classify theminto three broad types: redefinition, symptom escalation and crisis induction, and redirection. A list of individual andfamily patient characteristics and problems particularly applicable to each type of paradoxical intervention is presentedalong with contraindications for use. Last, implications for training and cautions as to their use are presented.

The Use of paradoxical interventions is enjoying widespread popularity in recent years as evidenced by increasingnumbers of papers (13). Although a potentially powerful and influential therapeutic tool, these techniques are ofteninappropriately used as substitutes for an effective understanding of family dynamics or as a "quick and easy" solution tocomplex therapeutic problems. Yet the clinical power of these approaches, when properly used, cannot be easily dismissed.

Working in a large, inpatient-outpatient teaching hospital, we found ourselves asked to consult with therapists who hadrun into therapeutic impasses with their patient families or individual patients. Working as a team, we observed andparticipated in several therapy sessions for each referral and then made a number of recommendations as to possiblecourses out of the impasse, using a paradoxical frame of reference. This experience led us to three general conclusions withrespect to the use of paradoxical techniques in clinical practice.

First, it became clear that paradoxical maneuvers could be categorized into a series of well-defined, relativelycircumscribed intervention strategies, each of which shared given theoretical similarities but emphasized different aspectsof the paradox. Such a cohesive frame of reference proved very helpful in devising specific interventions in particularclinical situations.

Second, we developed a hesitancy to suggest paradoxical interventions to therapists working with certain types offamilies or families presenting with certain kinds of problems, whereas with other families these techniques seemedappropriate and productive. What developed from this experience was a list of indications and contraindications for the useof these techniques in family-oriented psychotherapy.

Last, several cautions and considerations came into play in our efforts to train other professionals, whether colleagues orbudding family therapists, in the use of paradoxical maneuvers. The present paper will focus on each of these three topics.

Techniques of Paradoxical InterventionTo understand the development of a classification of paradoxical techniques and its application to specific types of family

problems, it is first necessary to briefly review some of the mechanisms under which therapeutic change under paradoxicalintent is thought to take place. In this way some linkage between the prescription for change and the theoretical process ofchange can occur.

Mozdierz et al. (6) report that Adler was probably the first to write about a paradoxical strategy in psychologicalintervention. Adler saw the paradox as a dialectic in which the patient simultaneously wanted and did not want to give uphis symptom. This dilemma escalated into a power struggle with the therapist who was seen by the patient as forcing thepatient into a one-down position in an effort to rid the patient of his ambivalently held symptom. In Adlerian terms, thepatient improved by an increase in self-esteem following a successful power move against the therapist who suggested thathe keep the symptom.

Frankl (2, 3) emphasizes a shift from studying the symptom in phobias and obsessive-compulsive patterns to a focus onobserving anticipatory anxiety surrounding the fear of the object or the thought, respectively. In sexual problems, the thirdsymptom area addressed in his writing, the same emphasis prevails: a shift away from actual sexual performance to the roleof spectator.

This shift of emphasis, in a sense an alteration of perspective from the symptom to the rules that govern its maintenance,has been the subject of more recent work by Watzlawick and his colleagues (12) and still more recent by Selvini Palazzoli

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and her colleagues (9). Watzlawick is quite explicit in terms of defining a mechanism of change. He suggests that changeoccurs through a process of "reframing," which is defined as an alteration in "the conceptual and/or emotional setting orviewpoint in relation to which a situation is experienced and to place it in another frame which fits the facts of the sameconcrete situation equally well or even better, thereby changing its entire meaning" (12, p. 95). In other words, the meaningattributed to the situation is altered or redefined and therefore its consequences change as well.

Selvini Palazzoli et al. (10), whose theoretical position tends to be based on Watzlawick's pioneering work, extendsthese underlying premises to suggest that the mechanism of change resides with the therapist's positive connotation of allbehavior. In this way the family is thrown into a bind by being asked to accept the positive qualities of the symptom theyambivalently ask to be rid of.

The notion of the double bind brings to mind the early work of the Palo Alto group and Haley's relatively recent writingscontinue in that tradition. Haley (4) suggests that all communication occurs at both overt and covert, or metacommunicativelevels. The latter message informs or interprets the former. He suggests that the therapeutic paradox clarifies thecontradictory messages often posed by overt and metacommunications by making them both public in an understandablemanner. More recently, however, Haley (5) has emphasized the use of analogy and metaphor. By clarifying these messages,often symbolically, the therapist can overtly accept the presenting and covert symptoms and literally suggest their repeated,perhaps accelerated occurrence, once a trusting relationship has been established. In this sense, the ambivalence expressedby the symptom's presence is taken by the therapist as reality, not as symbol. Interestingly, Haley emphasizes a componentof therapy that many others often omit; the effect of giving up a symptom on the family system and the necessity forincorporating family issues in the paradoxical therapy of individual patients.

Papp (7), in a recent paper on the work of the Ackerman group, describes the mechanism of change as a redefinition ofthe problem. Whereas the family enters treatment with the "problem" being their inability to remove the presentingsymptom, the therapist paradoxically ties the elimination of the symptom to a change in the family system itself; one cannotoccur without the other. The issue is no longer how to change the symptom but what will happen to the family if it ischanged.

Raskin and Klein (8) state three fundamental mechanisms of change following paradoxical intent(a) it attacks thepatient's power over therapy by undercutting the patient's control of symptom display; (b) it utilizes principles of humanlearning to extinguish, satiate, or aversively reduce the presentation of the symptom; and (c) it redefines the symptomwithin another frame of reference.

This review, admittedly brief and not exhaustive, has served to point up some of the similarities and differences withrespect to mechanisms of change postulated by various authors within the rubric of a paradoxical frame of reference. Afterreviewing these theorists as well as pooling our clinical experience with similar techniques, it became apparent thatinterventions based upon the paradox were those in which the therapist rechanneled the energy the family generated in aneffort to maintain the symptom by: (a) redefining it by giving the behavior another meaning; (b) escalating it by promoting acrisis or increasing the frequency of its expression; or (c) redirecting it by changing an aspect of the symptom. It alsobecame apparent that (a) insight was not required, although it often occurred as a spontaneous result of the technique; (b)symptom removal was not the initial goal because of the desire not to challenge the family's resistance; and (c) thetherapist's behavior was often unexpected and could not fit into the patient's existing cognitive or emotional structure.

These three strategiesredefinition, escalation and crisis induction, and redirectionplus the above three criteria wereused as a theoretical formulation and as a map for therapeutic intervention. It became clear that our paradoxical stancewould be maintained if we met the three criteria and utilized some form of one of the three strategies, given a particulartherapeutic impasse in a particular family.

It should be kept in mind, however, that these strategies need to be viewed within the context of family dynamics and notas external "techniques" to be rigidly applied in the presence or absence of given criteria. These strategies can be helpful inthinking through a particular therapeutic impasse but only after a thorough knowledge of the family's dynamics has beenobtained. More on this in a later section of this paper.

The classification of these strategies does not preclude a degree of playfulness or humor in their initiation or application.Often an idea for a paradoxical intervention seemed to emerge from the therapist as a kind of playful or even comicmaneuver. A categorization of approaches, such as the one presented above, does not preclude such modes or styles oftreatment; rather in our view it guides and channels them, assuring careful consideration of the dynamic picture presentedby the family.

Also, it was recognized that often more than one of the three strategies might be used at the same time and that in someways one therapeutic intervention contained aspects of more than one approach. Hence, these were seen only as roughguidelines, a kind of broadly based check sheet to assist in thinking through and deciding upon an approach to a givenclinical situation. What follows is a definition of each strategy, a description of the kinds of presenting family characteristicsparticularly applicable to each approach (see Table 1.), and a brief clinical example.

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Table 1Patient Characteristics Applicable to Three Types of Paradoxical Interventions

Reframing Escalation or Crisis Induction Redirection

Moderate resistance Vague style Individual Settings

Non-oppositional Super-verbal manipulation Presenting problem with young child

Not short term Oppositional Specific symptoms

Ability to reflect Power Struggle Repetitive symptoms

Non-action-oriented Marked resistance Educational & guidance setting

Can handle frustration & uncertainty Need to move quickly

Potential for acting out Family can respond to direction withoutundue sabotage

Little or no severe impulsive or acting-outbehavior

Excessively rigid

No pressing external problems Blocked with no area of compromise Non-oppositional

Rigid family structure Adults competitive with therapist Overly compliant

Repeated crisesnot severe

RedefinitionRedefinition is an attempt to alter the apparent meaning or interpretation the family places on the symptomatic behavior.

For example, in a simple case a child's negative provocativeness can be seen as a temper tantrum, but in a particular kind offamily setting it may also serve the purpose of uniting drifting parents. When such a redefinition of the "negative" behavioris identified and made public, its repeated occurrence is often made unnecessary. In this case, the symptom is then droppedby the "helpful" child.

This technique seems most appropriate with families possessing some capacity for reflection and insight, as opposed toaction-oriented families. Suitable families need to have the capacity to handle frustration for reasonable periods withoutacting out or without impulsive displays. Such families may present with repeated moderate family crises but without thekinds of problems requiring immediate and direct action. Often these families have relatively rigid structures, and theirresistance to change is judged as moderate without the occurrence of overt, hostile, oppositional behavior. In essence,families that seem most open to reframing techniques are those that can, at the minimum, reflect upon the therapist'sattempts to redefine the symptom, and whose problems permit some time for the process to occur. Also, their resistanceand view of the therapist are such that power struggles between patients and therapist and other forms of oppositionalbehavior do not dominate the situation.

An example of the use of redefinition occurred in the G family. This family was referred by a local pediatrician and camewith the chief complaint that the oldest child's seizure disorder was causing family problems. Living in the house at the timewere mother, father, identified patient Paula (age 11), sister (age 9), brother (age 5), and father's mother, who had come tolive with them following her husband's death. In the sessions, there was little discussion of mother's family, who lived inCalifornia. Mother was one of two children; her brother, two years older than she, was living in California near theirparents. It was as if Mrs. G had been absorbed into Mr. G's family when they were married and had no further contact withher own family.

Mr. G was a successful business executive who worked long hours and traveled to some extent. Mrs. G did not workoutside the home. She spent a great portion of her time involved with Paula's problem, chauffeuring the children, andcarrying out many of the tasks expected of her as the wife of a successful business executive.

Paula, the identified patient, looked younger than her stated age, had short hair, and was dressed in jeans and a tee shirt.She was described by parents as having a very complex and at times medically uncontrolled seizure disorder and was alsointellectually retarded. At the initial session, her sister, younger by two years, looked older than her stated age, sat with herparents, listened to the conversation, combed her hair, and in general was quite preoccupied with her appearance. Paula, onthe other hand, played with her 5-year-old brother.

In the first interview the discussion centered around Paula and her grand mal seizures, which were occurring at a rate ofabout one or two per week and seemed in many ways correlated with the level of tension in the home. Most of the family'stime was spent either in responding to the seizure itself or in seeking professional help around the problem. The family hadalready had a great deal of professional help around the physical problem and were now seeking help around the resultantfamily problem. Gradually the discussion left the children and the seizure disorder and focused on the parents, with

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grandmother correctly perceiving that there were conflicts between husband and wife around the management of the homein general. Grandmother's self-defined position was to side with the wife as she felt her role in the family was to keep thewife's spirits up in light of Mr. G's critical attitudes.

In this, as in all families, it was quite important to discover the homeostatic rules of the family: the rules necessary for thesystem to maintain its equilibrium. In this case it appeared that the women, mother and grandmother, were responsible formaintaining a "well-run house." Father was excused from this because of the demands of filling an upper management job;the expectation was that the house should be quiet and comfortable when he returned home. He was not called in untilthings were out of control, usually related to Paula's behavior, and then was criticized by the family for being too harsh inhis interventions. One method of intervention chosen by the therapists was redefinition. In this way, the system by which thefamily functioned was able to be maintained, although redefined in a more positive light. Father was defined and overtlylabeled the "real manager" of the house (as he was in his business) and was given the job of directing how things should bedone at home, as it was evident that he had very clear ideas of how the house should be managed in order to provide himwith peace and quiet. The women could still maintain their control over running the house by carrying out father'sdirections. Rather than devaluing father for being too harsh, he was vigorously applauded for his managerial service to thefamily, which took a great deal of responsibility off the women's shoulders and also kept the system functioning."Unfortunately," this relabeling brought to light the real underlying family structure, and although father liked the control heheld as manager, he was not sure he could handle the responsibility.

As with the other examples that will be presented, redefinition was only one part of the therapy with this family. Therewere other tasks related to increasing the closeness between the couple and tasks related to altering family responses toPaula's seizure activity. But redefinition of the problem from the family's responses to Paula's seizures to a problem offamily management under the direction of an unwilling executive "expert" presented the family with a task couched indifferent terms from their original conception. As can be seen in this example, the redefinition was incorporated into aknowledge of the family's dynamics and explained in terms of the family's idiosyncratic language, e.g., the businessmanager and the family manager.

EscalationTwo broad types of symptom escalation methods have been used. The first is similar in practice to early techniques

based on the learning theory principle of massed practice. For example, facial tics can be placed under voluntary control ingiven settings by prescribing their massed occurrence several times a day. This approach takes the response out of therealm of unconscious control.

A couple in their late fifties came for treatment because the husband was ruminating about his physical ills and wasdepressed. His "illness" threatened to call a halt to a long-planned trip to Florida, and his wife was both concerned anddisappointed. These symptoms came during the first year of his retirement from an active, successful career in insurance.His adjustment to retirement had been difficult because of the couple's lack of friends and interests outside the family. Hisfavorite daughter, who was currently experiencing marital problems, was extremely concerned about her father's health; shevisited daily and telephoned several times each day to learn of his condition. Attempts at gaining a better understanding ofthe dynamics of the symptom through other methods failed, and it was difficult getting the topic of conversation away fromthe husband's aches and pains and his dramatic requests for a cure. After several sessions, it became clear that the symptomserved the function for both husband and wife of maintaining a rather enmeshed and family-based way of life. Thehusband's retirement caused a removal of the major extrafamilial activity for both spouses. The symptom filled the void bychanneling the family's (including daughter's) energies toward "family" matters and prevented the couple from developingnew, extrafamilial contacts, which the Florida trip would certainly entail.

With all of this in mind, the husband was instructed to spend the next two days in one room dressed in pajamas andbathrobe preparing a log of his every thought and physical problem. He was also to record his blood pressure and heart rateat 15-minute intervals and to report to the "doctor" twice daily. This was to "increase" his depression so as to enable us tostudy it as well as to gather more data in an effort to understand his physical problems more clearly. Mother and daughterwere to help in this two-day effort by not allowing him to talk with them, by leaving him isolated in the bedroom, and bysetting a tray with his meals outside his door without conversation so that "he could concentrate more effectively." Althoughthis task was difficult, all parties succeeded. The technique here was to escalate the symptom as well as to redefine anaspect of the symptom by legitimizing it for purposes of the "doctor's cure." Needless to say, the husband became "sick" ofhis task and went to Florida instead. Again, the prescription for change was seen within the dynamics of the family and notas an isolated technique to be used regardless of setting.

The second type of symptom escalation aims at increasing in intensity or frequency certain aspects of a clinical situationby provoking a crisis. At times the patient or family is forced to deal with the feared situation, but in all cases the crisisundermines a rigid family defense and forces a decision or some kind of action.

An illustrative family in which this technique was used included a 42-year-old successful father who was a member of a

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suburban school board and active in the local Catholic church, a 40-year-old mother who managed the home and workedpart-time in a retail children's clothing store, and four children: a boy age 18; Betty the identified patient, age 16; and a girland boy, ages 14 and 11, respectively. Betty was referred because management problems both at home and at school hadescalated to the point that the school threatened suspension because of skipping classes and parental attempts at disciplinewere failing.

Betty had become pregnant 16 months previously and had given the baby up for adoption because of parental pressure.Although from time to time Betty agreed that this decision was wise, she claimed she really had no say in the matter, andboth she and her mother were having difficulty working through the loss. The other family members, however, describedthe family as happy and congenial except for the tension caused by Betty's flagrant violation of parental demands.

Father, a successful corporation executive, was used to having his way, although his wife frequently stood up to himprecipitating a full-scale battle whenever she pushed an issue. With Betty, however, he felt threatened and was enraged ather lack of compliance, threatening her possible removal from the home if her behavior did not improve. Mother reluctantlyagreed. The therapists believed that mother was covertly encouraging Betty's negative behavior because of her ownunresolved and unexpressed anger at her husband regarding the decision to give the baby up for adoption. Somehow shebelieved father was to blame for the entire episode.

In treatment, all efforts at sidetracking, redefining, supporting, and interpreting failed, and Betty's negative behaviorincreased with mother's subtle encouragement. The therapists, feeling somewhat paralyzed by father's attacking style and bytheir reluctance to take sides, decided to provoke a crisis by permitting the negative behavior to escalate to some crucialevent and then to suggest that father was right all along, that the situation was untenable, and that perhaps Betty should beremoved from the home. When Betty stayed out all night with a "friend" without her parents knowing her whereabouts, thetherapists decided the time was ripe and the crisis was provoked. The family was covertly shocked but overtly inagreement, and they were sent home with lists of foster placements, residential schools, etc. Needless to say, they returned aweek later reporting literally hours of family discussions, a markedly reduced level of family tension, and a decision to keepthe family intact. In this example, the locked battle between father and mother on the one hand and Betty and father on theother was undermined by provoking a family crisis in order to force a realignment of positions and permit options for actionwithin the family.

These techniques seem most applicable when family resistance is extreme, some form of oppositional behavior ispresent, and the family has successfully walled off all areas of compromise and problem-solving. By admitting defeat orescalating to the point of crisis, the therapist gains an upper hand in short-circuiting vague complaints, circumventingparalyzing resistance, or outmaneuvering the superverbal and overly logical family. This "end-running" tactic is oftensuccessful with excessively rigid, domineering, or autocratic families in which battles for control potentially underminesuccessful outcome.

Of particular concern, however, is the issue of timing. Crisis induction, in particular, requires careful planning as well asa series of frustrating sessions in which every attempt is made to use other, less stressful techniques. If the technique isapplied too early, it will fail because of a lack of sufficient tension built up from previous failures at change. If applied toolate, the family may have left treatment or given up, or an external crisis of more serious magnitude may have developed. Ingeneral, then, this technique seems most applicable with families that are excessively rigid, resistant, and highly skilled atbeing vague or overly explanatory in an effort to prevent change.

RedirectionThis technique is similar in some ways to symptom escalation, in that both attempt to place the symptom under voluntary

control. Whereas in escalation the symptom is removed by satiation under massed display or by provoking a crisis, inredirection the circumstances under which the symptom is to occur are prescribed, although the frequency is not necessarilyaltered. Redirection, like the other techniques, is applicable in both individual and family treatment, provided thatknowledge of the family system is integrated into the conceptualization of the symptom.

A form of redirection was helpful in working with a hospitalized 45-year-old woman of Dutch origin with numerousphysical complaints bordering on somatic delusionse.g., "I feel as if there is a hole in my esophagus through which foodescapes into my insides." She had five hospitalizations over the previous nine years, each time carrying the diagnosis ofschizophrenia. Her 19-year-old son was currently being prosecuted for check forgery following a six-year history ofcontinual scrapes with the law. Her 21-year-old daughter, a well-functioning woman who was her father's pride, had justmarried two months earlier. The identified patient's husband, a competent supervisor of highly skilled mechanics, wasfinding it increasingly difficult to ignore his wife's continuous physical complaints. In family sessions it became apparentthat she began ruminating about her body whenever angry exchanges between family members threatened to break out. Herhusband had longstanding resentments about the restrictions on their social lives caused by her physical problems. The wifehad major unexpressed disappointments with her husband going back to, among other things, his unresponsiveness elevenyears earlier when she miscarried an intensely anticipated baby. It seemed that anger between them over these

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disappointments threatened the only emotionally supportive relationship for each of these two middle-aged people whowere isolated from their families of origin in Holland. On the inpatient unit the woman quickly established a pattern ofcomplaining to staff about her symptoms.

Redirection was used with the intent to clear the field for the very difficult marital and life problems to be approached.On the unit, staff were instructed to listen to her talk about symptoms for only ten minutes every evening at 10:00 P.M., andshe was instructed to approach staff at that time even if she felt no urge.

In the family sessions, symptom talk was deferred until the last five minutes, and the family negotiated together a time forsymptom talk during her visits home. Simultaneously, the family sessions supported the very difficult work of their hearingeach other's anger and disappointment. As expected, the intensity of her symptoms subsided, both in terms of amount oftalk and of her subjective experience of the symptoms.

Clearly, in this case, the paradoxical maneuver was only one part of what can be seen as the difficult treatment of asevere marital problem. In addition, this particular kind of intervention required, in part, the family's willingness to complywith the therapists' directives for symptom talk both during the sessions and at home.

This technique is appropriate when resistance is low, when little oppositional behavior exists, and when the family canfollow through on directives without undue sabotage.

ContraindicationsParadoxical techniques, while powerful in many settings, can be equally harmful if misapplied. These techniques deal

directly with other fundamental family defenses and when ineptly applied can lead to a flight from treatment or to moresevere crises. In fact, we suggest that of all the therapeutic interventions we have tried in clinical or consulting settings,paradoxical interventions constitute the highest risk for subsequent no-show appointments and premature terminations.This demonstrates their power, but it also indicates the need to apply these interventions carefully, in a skillful andwell-timed manner, with families, couples, and individuals with whom the risk of negative outcome is small.

There are several kinds of families with which the use of paradoxical techniques as a major therapeutic modality is illadvised. Paradoxical techniques seem least applicable in chaotic families (1), with loose and variable structures. In suchfamilies, it is often difficult to gain hold of a concrete issue to work on, and the aim of therapy may be the establishment ofsome kind of internal cohesion and stability rather than on eliminating particularly troublesome behaviors. Oftenparadoxical ploys are used to undermine powerful family coalitions aimed at resisting change. In chaotic and poorlyorganized families, however, there are insufficient positive and negative collusions and alliances to begin with, makingthese techniques inappropriate. The use of the paradox may be appropriate at later stages of intervention when somesemblance of internal structure becomes stabilized and the focus shifts to other directions.

Similarly, paradoxical maneuvers are not appropriate with childlike families (1), in which all members, including adults,tend to function on an immature level seeking parenting from the therapist. Such systems are again too loose and lacksufficient cohesiveness and unity of purpose for a paradoxical ploy to be effective. Often such families see the interventionas another rejection from a parental figure, and their need for parenting either leads to a search for a new mother or fatheror to an unproductive rebellion against the therapist, thereby compounding the problem.

Some kinds of impulsive families (1), families with members who overtly express conflict in the community or at homein a socially undesirable or potentially harmful manner, are also inappropriate for paradoxical intervention. In this case,careful consideration of such techniques as escalation needs to occur in order to prevent potential harm. For example,depressive or aggressive symptoms should not be exaggerated in families in which the risk of suicide or physical harm toself or others is a real possibility. Yet in other families in which the same style is present but the degree of symptomexpression is less, these techniques may be highly appropriate to force the family into action. Again, careful clinicaljudgment should prevail.

Insight-oriented, structural, or other kinds of interpretive techniques may be more helpful in stimulating growth thanparadoxical techniques in families that are already demonstrating solid therapeutic movement. Paradoxical ploys are alsoinappropriate in families seeking therapy to resolve specific developmental or situational crises in which support,information, or guidance seem more appropriate. These are families that have the resources to manage the presentingdifficulty but need a setting in which to work issues through or professional support and direction in solving their ownproblems.

Last, these techniques seem little suited to families that accept responsibility for their own behavior, in which therapeuticinterventions are accepted at face value with minimal oppositional or negative behaviors, or in which control of therapy interms of course and direction are well agreed upon and remain an unconflicted area of interaction. In general then,paradoxical procedures are contraindicated when marked resistance, power struggles, and oppositional behavior areminimally present, when family structure is so disorganized that family solidarity is minimal, or when a potential for sharpescalation of symptoms or other severe forms of acting-out behavior with strongly negative consequences is possible.

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ConclusionsOther than their use by well-known (11) and often charismatic figures, little has been written about the planning and

implementation of paradoxical procedures in everyday clinical practice. In our view, this has led to frequent misuse of thesepotentially powerful procedures, which often are employed as excuses for lack of skill or insufficient diagnostic study. Whatis clearly needed, given this situation, is more detailed study of the kinds of clinical situations that are most open to their useas well as to potential negative effects.

In our experience, the failure of a paradoxical intervention is most usually due to a lack of understanding of the dynamicsof the family. Frequently, a therapist will come up with a spur-of-the-moment ploy, an off-hand idea based upon limiteddata. Although even the most bizarre of ideas often have merit in their absurdity, we found it necessary to set up twoprimary cautions about our interventions in order to reduce the chance of failure or a more serious outcome, prematuretermination. First, we agreed that all paradoxical interventions should be discussed with the consulting group prior toinitiation. Such a consultation insured a carefully thought-through intervention by opening the case up to group scrutiny. Inaddition, the group was able to assist in maintaining a paradoxical set by assuring that systems dynamics were beingproperly considered, and by preventing regression to more linear modes of thinking, as often happens in solo practice.

Second, paradoxical interventions require a clear understanding of the family's symptom and the role the symptom playsin the life of the family. Each family member's stake in the maintenance of the symptom needs to be understood in detailfrom an individual as well as from a systems perspective. As such, our team agreed upon the necessity of a complete familyevaluation prior to initiation of the intervention. Such an agreement reduced the chances of impulsive and therapeutic ploysthat have little chance of success, not because they spontaneously arise from the clinical situation, but because often theyare not carefully thought through. We learned again and again that the effective use of a paradoxical intervention requires athorough knowledge of the family as a dynamic system.

Unlike many other types of therapeutic interventions, the approaches under discussion here require a change of set, anability to look at what is clinically presented with a new pair of glasses, and an ability to deal effectively with the absurd,often with humor. It is quite apparent that not every therapist is suited to this kind of work in terms of style and generalpersonality. Of all the methods of intervention we have utilized in the course of clinical experience and training, we havefound no other in which such stylistic issues play such a powerful role. For example, there are some trainees who simplycannot carry off the interventions in a meaningful and convincing manner. Their physical presence, appearance, and way ofrelating preclude an effective intervention and sharply reduce their ability as clinical change agents using this technique.While of concern in other modalities of therapy as well, this issue appears crucial in paradoxical work. Therefore, we havefound it necessary to thoroughly think through whether or not a recommendation for the use of a paradoxical technique willbe productive given the personality and style of the therapist, whether trainee or staff. There is little question that therapistvariables play a powerful role in the success or failure of these techniques.

As a side note in this regard, we have found a particular lack of success in teaching paradoxical techniques to very youngor inexperienced therapists. Somehow they have noticeable difficulty in carrying off the intervention, even with groupconsultation and support. Two reasons come to mind for our first-year trainees' singular lack of success in this area. First,as mentioned above, these techniques require a finely tuned sense of timing as well as a degree of patience. New andinexperienced therapists often need continual exposure to patients over time to develop this skill; consequently, training inparadoxical formats may be best postponed to later in their training. Second, paradoxical strategies often deal with rigidfamily defenses that frequently lead to therapeutic impasses and binds. We have found that novice therapists do not have thefirst-hand experience of wrestling with the impasse, of experiencing the paralysis of a resistive family, and of developing agut reaction to the family's desire to entrap the change agent and render him powerless. Such experience takes time todevelop, and pushing young therapists into the use of paradoxical strategies in our experience often leads to the use of"cookbook" modes of intervention without the conceptual and experiential understanding of the therapeutic wrestlingmatch.

Our experience with paradoxical techniques has in general been positive and successful when incorporated both in broadclinical practice and in training activities in which a number of approaches were utilized, depending upon the problem athand. Although the paradoxical bandwagon has many "avant-garde" therapists jumping aboard, our experience indicatesthat the techniques are effective when, like all intervention strategies, they are well thought through and appropriatelyapplied.

REFERENCES

1. Fisher, L., "On the Classification of Families: A Progress Report," Arch. Gen. Psychiat., 34, 424-433, 1977. 2. Frankl, V. E., The Doctor and the Soul: An Introduction to Logotherapy, New York, Alfred Knopf, 1957. 3. Frankl, V. E., "Paradoxical Intention and Dereflection: Two Logotherapeutic Techniques," in S. Arietz and G.

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Chrzamowski (eds.), New Dimensions in Psychiatry: A World View, New York, John Wiley, 1975. 4. Haley, J., "Paradoxes in Play, Fantasy, and Psychotherapy," Psychiat. Res. Rep., 2, 52-58, 1975. 5. Haley, J., Problem-Solving Therapy, San Francisco, Jossey-Bass, 1976. 6. Mozdierz, G., Maccitelli, F. and Lisiecki, J., "The Paradox in Psychotherapy: An Adlerian Perspective," J. Individ.

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