Journal ofmedical ethics, 1990, 16, 200-205

The ethical use of paradoxical interventionsin psychotherapyD M Foreman University ofKeele, Stoke-on-Trent

Author's abstractThe purpose of this paper is to establish ethical guidelinesfor the use ofparadoxical interventions in psychotherapy.These are defined as interventions which are

counterintuitive, coercive, and which require non-observance by the client. Arguments are developed to showthat such interventions are associated with a psychologythat understands individuals solely in terms oftheirrelationship: a 'strong interactionist' position. Ethicalprinciples consistent with such a position are considered,andfrom these it is derived that: paradox is an ethicaltechnique with resistive patients; it requires consent; itscontentshould be consistent with general ethicalprinciples,especially those of beneficence and non-maleficence;non-paradoxical techniques should be preferred whenpossible; and it should not be used as an assessmentprocedure. It is concluded that research is needed to explorethe effect ofsuch ethicalguidelines ofeffectiveness, thoughpreliminary impressions are encouraging.

IntroductionLike many other therapeutic techniques, a simpleparadoxical approach may be found among the skillsused by a mother in managing her child. For example,a child who is fussy about food may be told about a new

dish that the mother thinks is delicious, but which'might not be suitable' for the child. Ofcourse, the ideais to make the child want the food so much that he orshe 'persuades' the mother to give him or her the food.Therapists have a wide range of such techniquesavailable to them (1): they may prescribe the verysymptom the client(s) have requested them to alleviate;they may recommend that things do not change whenthey want them to do so; perhaps they may evencomment that any alternative to the current situationwould be worse. However, the rather underhandnature ofthese techniques has led some authors (2,3,4)to question whether such techniques can be used by an

ethical therapist. The purpose of this paper is toidentify a generally acceptable group of ethicalprinciples that are relevant to paradoxicalinterventions, and from them derive guidelines fortheir ethical use.

The Nature of the ProblemDEFINING PARADOXICAL TECHNIQUE

Though paradox is easy to recognise, it is more difficultto define, as different therapists have presented widelydifferent rationales for it. Thus Dunlap (5) saw it asestablishing voluntary control over previouslyinvoluntary habits; Adler (6) and Kraupl Taylor (7)considered that it made positive use of the patient'sresistance to the therapist; Erickson (8) saw it as beingrelated to hypnotic suggestion; Frankl (9) saw it as

establishing an existentially authentic distancebetween the symptoms and the sufferer; Haley and hisfollowers (10,11) believed that one was correctingsymptom-producing interactions between familymembers; while more recently (12) it has beenproposed that such interventions disrupt existingfamily patterns, forcing the family to change in order tomaintain its integrity. Whatever the theoreticalbackground, the interventions described tend to havethree qualities in common: they are counterintuitive;they require that the therapist's suggestion not becarried out ('non-observance'); and they are coercive(12,13). For example, consider the mother and herfussy child described above: suggesting to the childthat the food might not be suitable is at first sightcounterintuitive; the mother wants her child tochallenge that statement; and the mother is making useof the child's oppositional behaviour to force the childin the direction she wants. The 'force' of the coercioncomes from the mother making use of a characteristicof the child without the child having any say in thematter.One model is not included in this; the behavioural

approach of Dunlap (5). However, his approach, ofrepeatedly practising the behaviour (usually a tic) thatone wishes to get rid ofwould now be seen as a form oforthodox behaviour therapy called flooding (14),where a behaviour may be repeatedly elicited till itceases to occur (a process called extinction).

Key wordsPsychotherapy; ethics of psychotherapy; paradox; familytherapy.

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A FUNDAMENTAL ASSUMPTION IN PARADOXICALPRACTICE

Despite the markedly different theoretical bases ofdifferent 'paradoxical' therapists, they all hold what Ishall call the 'strong interactionist' position: that is, forthe purposes of paradox they all assume that theindividual can be completely and essentially describedby the frame of relationships including him or her. Inother words, the individual has no existence apart fromhis/her relationships. As a statement aboutindividuality it is, at the very least, incomplete;however, it can be found as an assumption in all themodels of paradoxical practice referred to above. It isregarded as being one of the implications ofa 'systems'approach in family therapy (15), which group are thelargest users of these techniques (1). Erickson (16)accepted a 'systemic' reformulation of his own work;and Adler (17) considered that all human behaviourderives from the configuration of power-relationshipsbetween people. Frankl's 'Paradoxical Intention' is a

special case of his concern with those neuroses whichhe considers reflect the 'existential vacuum' common

to all. The ontogeny of this vacuum has been discussedby Sartre under the heading of 'nothingness' (18).Starting with Husserl's contention that in order to beconscious, one must be conscious of something, heargues that the perceptually conscious entity has to beaware of its own consciousness in order to use it. Thisstate he refers to as 'being for itself as opposed to theunconscious 'being in itself'. In order to be conscious,consciousness must therefore distance itself fromitself, and the sense of alienation resulting was

characterised by existentialists as a gap; the 'existentialvacuum' or 'nothingness'. Thus, the individual comesinto being through a relationship - a StrongInteractionist position. Kraupl Taylor's overallapproach to psychiatry, from an analytic andphenomenological background, accepted the existenceof individual characteristics that could not betranslated into relationships. However, he consideredthat those clients suitable for his 'paradoxical'approaches were those whose behaviour was

completely at the mercy oftheir transference reactions,and who had thus lost individual autonomy apart fromtheir relationships (7). He thus considered them to bein a situation that would make 'strong interactionist'assumptions valid.

THE IMPACT OF THE 'STRONG INTERACTIONIST'POSITION UPON ETHICAL DECISIONS

The 'strong interactionist' position takes a view of theindividual that is not typical or generally agreed.Maclntyre (19) has pointed out that one's world-viewcrucially affects one's ethical decisions. Thus, one may

expect to find some 'paradoxical' therapists honestlyespousing practices that would not be consideredethical by most people, or alternatively seeking new

ethical systems that might better include theirviewpoint. This is in fact the case. Haley (20) arguesthat the therapist is entitled to mislead the client if he

deems the outcome of this is beneficial ('the benevolentlie'). Other 'paradoxical' therapists insist thatinformed consent is in fact antitherapeutic in theirparadigm, as it renders paradoxical approachesineffective (21). Lakin (22) describes a trainingvideotape which shows a boy having his mouth coveredwith adhesive tape as a response to his persistentrefusal to speak in a family session. Arguments havealso been presented by family therapists workingwithin this perspective (23,24) for a re-definition ofpsychotherapeutic ethics to allow a more flexibleinterpretation of individual rights in therapy,especially specifically to include the idea of theindividual as a locus of relationships. It can bedemonstrated that these views represent the 'stronginteractionist' position rather than a family therapyperspective by considering family therapists who donot take such a perspective. Hare-Mustin's (25,26)feminist approach is not 'strong interactionist' in that itassumes relationships are predicated by, and sosecondary to, gender identity. Patterson's (27) sociallearning approach is not 'strong interactionist', as itdoes not ascribe to relationships a privileged role in thedefinition of the individual - they are simply anotherset of potential rewards for the right behaviours. Bothof these workers emphasise the value and usefulness ofinformed consent. Additionally, Hare-Mustin sees adanger of covert paternalism in paradox (or othercoercive interventions) while Patterson (28) suggeststhat client non-compliance, for which paradox is saidto be most effective (13,29) may be a function oftherapist style.

Qualities that should characterise an ethicalposition for paradoxical therapistsTherapists are also people. Though their role mightafford them some privileges as citizens, it is difficult toimagine that therapists could obtain, or be allowed towork if people knew therapists did not conform to themoral principles of their clientele. On the other hand,those principles should be sufficiently broad to allowthe therapists scope to do good, otherwise suchprinciples would themselves not be moral (30).Beauchamp and Childress (31) have presented fourprinciples: respect for autonomy; beneficence; non-maleficence, and justice, which, they argue, haveespecial relevance to medical ethics. Gillon's furtherexploration of these principles (32) suggests that theymaintain their integrity even when applied tosituations in medicine where interpersonalrelationships are paramount. Therefore, they are likelyto be sensitive to the special needs of the 'stronginteractionist' position, while at the same timeconforming to the ethical requirements of ordinarymoral society.

Deriving guidelines from the principlesTo be valuable, the ethical principles suggested aboveshould both enable one to recognise the circumstancesin which a paradoxical approach is ethical, and to

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202 The ethical use ofparadoxical interventions in psychotherapy

distinguish between ethical and unethical approachesof this type.

RESISTANCE AND THE ETHICAL USE OF'NON-OBSERVANCE'Of the three characteristics of paradox describedabove, the expectation that the client will resist - whichI shall call the requirement of 'non-observance' - is theone that gives paradox its unique character (12).Essentially, one misleads clients by telling them, withapparent sincerity, something that you want them todisagree with. Intuitively, it seems ethical for theparent with an everyday problem with an awkwardchild, but the therapist's position is different in twoways. Firstly, the therapist is using deceit to promotechange in a central part of the client's life. Secondly,the therapeutic relationship, unlike that ofparenthood, involves a consenting agreement by bothparties. It is much harder to justify deceit when theclient has a right to evaluate the therapeuticrelationship, and therefore has an entitlement toaccurate information.

In therapy, the client places his trust in the therapist,in the belief that the therapist can help him. To do thissafely, the client must assume that the therapistpossesses two virtues (as well as professionalcompetence). The therapist must have honesty, as theclient must be able to assume that the therapist is notmisleading the client in agreeing to help him. Thetherapist must also have dependability, as the clientrelies on the therapist to help him through thedifficulty the client has brought.

In therapy, resistance may show itselfin a number ofways. Clients may repeatedly fail to carry out tasksrecommended by the therapist; or they may avoid thediscussion of issues salient to their difficulties. Themore the therapist perserveres, the more the clientrefuses, and therefore the client may become cut offfrom paths of improvement previously open to him orher. Thus, the client who responds in a resistivemanner to the therapist places the therapist in anethical quandary. If the therapist gives the client the'right' advice, the therapist ceases to be dependable, asthe client may deteriorate. If the 'wrong' advice isgiven, the therapist may remain dependable (resistanceno longer closing the paths to improvement), but at thecost of his honesty. Doing nothing, once in therapy,deprives the therapist of both virtues. Not agreeing totreat the client in these circumstances also seems to beunethical if, as the 'paradoxical' therapists claim, aneffective treatment exists and the clients would changeifthey could. It has been pointed out (33) that one owesa duty of non-abandonment to one's clients, by whichis meant that, having begun a therapeutic relationship(and thereby implying that therapy is of benefit to theclient), one may only terminate it at either the requestof the client, the successful completion of the therapy,or by a transfer to another therapist (that term nowbeing interpreted in its broadest sense). This is becauseby abandonment one deprives one's client of a benefit,

and so breaks the principle of beneficence to which asa carer one is committed.

In this situation, a choice must be made betweenhonesty and dependability. It is not possible to argueconvincingly that either is more important that theother. Foot (34) comments that such a choice ofprinciples may be regarded as elective, it being morallycorrect to make such a choice a matter of personalpreference. However, whose choice should it be? Thetherapist has no claim to expertise in such a choice:thus, the principle of 'respect for autonomy' wouldseem to require that this choice be made by the client.This implies that a 'paradoxical' therapeutic approachrequires the consent of the client.This analysis has further implications. The ethical

justification of paradox is based on a situation wherethe therapist is being forced to choose between honestyand dependability. Where the choice is not forced, theclient is entitled to expect both. Thus, when bothparadoxical and non-paradoxical treatments areequally possible and effective, or the effectiveness ofboth is equally uncertain, one should choose the non-paradoxical approach. A corollary of this is thatparadox should only be employed after a thoroughassessment has been made, and may not be used as anassessment technique. It is not sufficient to obtain a'blanket' consent for paradox at the outset. Wherethere is no resistance, to request such consent would beto invite the client voluntarily to give up the right toexpect the virtue of honesty, which would deprive theclient of his or her ability to evaluate the therapyaccurately. When there is resistance the client, as wehave seen, does not allow both honesty anddependability to coexist in the therapist, and the'consent' is in fact an invitation for the client to choosewhich virtue he or she prefers.

It is inconsistent to insist that any insight intoparadox will ablate its effect. All the authors onparadox agree that it is prescribed in circumstanceswhere (for whatever reason) it is deemed that insightwill have no impact upon the client. There seems to beno reason to presume that insight into paradoxicaltechniques is any different from insight in general, andso one can presume it will not change anything. Suchhas, in fact, been this author's experience in usingparadoxical techniques with adolescents - they quicklycatch on, but respond nonetheless.

THE LIMITS OF JUSTIFIABLE COERCION IN PARADOX

Though the problem of coercion is usually coupledwith consent, it needs to be dealt with separately here.The problem is that, in paradox, coerciveness is closelyrelated to effectiveness, as it will be used in situationswhere the client will be unable to make decisionsfreely. Such a limitation severely comprises the client'sautonomy, and such coercion is not thereforeincompatible with 'respect for autonomy' if it results ina greater range of options becoming available to theclient - in the first example, the child ends up with agreater choice of foodstuffs than before. Such a

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justification is, of course, a special case of 'the endsjustifying the means', and therefore requires furtherqualification. Firstly, it assumes that non-coercivealternatives will not lead to the same result, which mayonly apply in the presence of resistance. Secondly, themeans, as well as the ends, must be beneficent and non-maleficent. Thus, Madanes (35) considers thatparadox is contraindicated in cases of intrafamilialsexual abuse, and Kraupl Taylor (7) warns against theuse of paradox in depression; in both cases becausenon-observance might be difficult to ensure. The dutyofnon-abandonment also crops up here - one wishes toencourage resistance, but such encouragement mayalso unduly influence the client to terminate therapybefore it is of benefit, or at least harmless, to do so.Finally, the adhesive tape incident described by Lakin(22) suggests that justice must be a major considerationin the choice of any coercive therapy.

HOW INCOMPREHENSIBLE SHOULD PARADOXICALTHERAPIES BE?

The counterintuitive nature ofparadoxical approachesdoes not seem to warrant great ethical concern. Intrusting experts to be expert, we must allow them thefreedom to make use of their expertise in interpretingthe problems they are asked to address, and it is notnecessary (in the logical sense) that the expert'sunderstanding will be immediately comprehensiblewithout special training. However, the expert doeshave a duty (derivable from the principle of respect forautonomy) to make any explanation sufficientlycomprehensible to the client to ensure that the client isable to make a real decision regarding a treatmentoption, and not simply have to agree in total ignorancewith the therapists. Thus, as with any other procedure,both the advantages and the disadvantages of aparadoxical approach need to be conveyed to the clientwhen consent is sought.

Paradoxing more than oneThere seems to be no reason for regarding any of theguidelines derived so far as being inapplicable to thegroup or family setting. Paradoxical approaches tendnot to be employed in group therapy, and so thissetting will not be considered further; however,paradox is probably used most frequently of all infamily therapy. The family setting especially poses anadditional ethical problem: there may be only onemember who is experiencing difficulties in living.What are the ethical grounds for applying techniquessuch as paradox to people who wish to help, but whomay have no problems of their own?To argue that they need to change because they have

problems by virtue of there being an identified client isdisingenuous. Even within a 'strong interactionist'perspective, it is possible for all of a person'srelationships to be adaptive except those with theidentified client, and the client to have equallymaladaptive relationships to all. In that setting, it ishard to argue that anyone except the identified client

should be required to change.The four principles of respect for autonomy,

beneficence, non-maleficence and justice must applyequally to all. However, in a family not all are equal.Especially, the children may only achieve those rightsat the behest of their caretakers. Therefore, in order tobe just (following Rawls's interpretation of 'justice asfairness' (36)) the therapist must support the childrenagainst the caretakers in any conflict of interest.However, the therapist is limited by this sameprinciple, in that the child has no greater entitlementthan the caretakers, and so the caretakers' interestsmust also be served as far as equitability allows. Thishas the corollary that, despite recognising theinteractions between family members, the therapist isrequired to give primacy to the individual needs offamily members, and especially any children. Theseindividual needs ofcourse include ethical treatment foreach individual.The power relations in the family mean that any

action consented to by the 'family as a whole' may beheavily weighted in favour of the most powerfulmembers, the caretakers. To ensure ethicalequitability for all the family members, suchagreements should be confirmed individually for allthe family members involved, taking into account theirindividual capacities (CfLo Cicero (37)). After this it isfair to use paradoxical techniques to improve thesituation of the children, even if it does not improvethat of the caretakers, as the caretakers are more ablethan the children to improve their lot. However, to beequitable, the lot of the caretakers should not beworsened by such an approach.

It is probably inadvisable to use paradox thatinvolves the children to benefit the caretakers, unlessthe paradox is designed materially to benefit thechildren also. This is because children are morevulnerable to their caretakers than vice versa, and thusin the interest offairness it is important to take positivesteps to protect them from any potentially negativeconsequences ofchange, as they will be less able to takethose steps themselves.

Conclusion: Does the adoption of ethicalconstraints impair the therapeuticeffectiveness of paradoxical interventions?One may conclude that:

1. Paradox is an ethical technique with resistiveclients.

2. It should therefore be used only after an assessmentand not as part of an assessment procedure.

3. Non-paradoxical techniques should be preferredwhere possible.

4. It requires consent.5. Its means, as well as its ends, should embody

generally accepted ethical principles.

However, as has already been observed (30) suchguidelines would not themselves be ethical if they

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204 The ethical use ofparadoxical interventions in psychotherapy

crippled an effective technique.To date, there is no research that has considered the

impact of consent upon paradoxical interventions, noris there a direct comparison of paradox when given aspart of, or separate from, an assessment procedure.

However, the first and the last ofthe principles listedabove both have a little support from the meta-analysisof outcome studies of paradox by Shoham-Salomonand Rosenthal (38). Their definition of a paradoxicalintervention included 'symptom prescription' and/or'positive connotation'. In the former, the therapistadvises the client to do everything possible to bring onor worsen the symptoms. In the latter, the symptomsare identified as having some beneficial role, and theclient praised for so using them. Both of these areconsistent with my own criteria: they are clearlycounterintuitive; both require the client either to failin, or reject the injunction in order for them to besuccessful; and both rely on producing an effectindependent of the patients' volition, ie are coercive.The authors found a highly significant trend for

paradox to become more effective with increasingseverity of symptomatology, while non-paradoxicaltreatments became less so. It seems likely (though byno means certain) that highly resistive clients, andthose who have failed simpler treatments, would beamong the most symptomatic. These results are thusconsistent with an assertion that restricting paradox tosuch a clientele will not prevent those who needparadox from having it. The second finding ofrelevance here was that paradoxical techniques thatinvolved 'positive connotation' were superior to thosetechniques that did not. This technique, with itsemphasis on personal competence and worth of theclient, is in keeping with a principle of aiming atbenefit for the client whenever possible (beneficenceand non-maleficence). This last guideline, of ethicalmeans, may thus be an important therapeutic, as wellas ethical principle.

Further research to address these issues directlyneeds to be done. However, the suggestion is that thedevelopment/acceptance of ethical guidelines inparadoxical interventions may lead to more effectiveuse of the technique, rather than the reverse.

Dr D M Foreman MB MSc MRCPsych is SeniorResearch Fellk= in the Department ofPsychiatry, Schoolof Postgraduate Medicine and Biological Sciences,University ofKeele.

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