Paradoxical Intention Is a Therapeutic Proced

Psychological Reports, 2004,95,946-948. O Psychological Reports 2004

USE OF PARADOXICAL INTENTION IN THE CONTEXT OF ACCEPTANCE AND COMMITMENT THERAPY '

WILLIAM G. SHARP, KELLY G. WILSON, AND STEFAN E. SCHULENBERG The University of Mississippi

Summay.-The purpose of this paper is to describe the use of therapeutic paradox within the contextual-behavioral treatment called Acceptance and Commitment Therapy. Emphasis is on the difference between inherent and constructed paradox, expanding on previous work and emphasizing Acceptance and Commitment Thera- py's relationship to Logotherapy.

Paradoxical intention is a therapeutic procedure aimed at circumventing maladaptive consequences of anticipatory anxiety by encouraging clients to increase their exposure, often in a humorous vein, to the event, thought, or behavior previously avoided (4, 5). Developed by Frankl in the 1920s, this approach is one of the core and most well-researched Logotherapy techniques (10). Although historically linked with Logotherapy, the basic ideas of paradoxical intention have been incorporated into other schools of therapy (1). For example, Ascher (1) noted that Milton Erikson implemented a series of therapeutic strategies that encouraged clients purposefully to exhibit maladaptive behaviors in a more extreme fashion. Although strkingly similar to paradoxical intention in form, Erikson did not explicitly use the term to describe his procedure. Behavior therapists have also incorporated paradoxical intention into their larger repertoire of treatment techniques and, in contrast to Erikson, have frequently adopted the term coined by Frankl (5). A number of behavioral outcome studies focusing on the efficacy of paradoxical procedures in the treatment of sleep difficulties and anxiety disorders has increased (9). For example, there is empirical support for the use of paradoxical intention with sleep-onset insomnia, agoraphobia, and public-speaking anxiety (10). Other authors have provided initial empirical support for the use of paradoxical intention within behavioral treatment regimes aimed at alleviating other clinical complaints, including urinary retention, functional encopresis, and ob- sessive disorders (2). Although integration of paradoxical intention in behavior therapy ap- pears well documented (2, 9), little attention has been paid to the applica-

'Address correspondence to Witliam G. Sharp, Department of Psychology, The University of Mississippi, University, MS 38677 or e-mail ([email protected]). PARADOXICAL INTENTION IN THERAPY 947 tion of therapeutic paradox within the other movements in psychology, such as contextual-behavioral movement. A recent and expanding contextual-behavioral treatment called Acceptance and Commitment Therapy is an alterna- tive therapeutic paradigm using paradoxical intention as "an important com- ponent" (6, p. 84). While integration of paradox in Acceptance and Commitment Therapy could be viewed as an example of the close relationship between Acceptance and Commitment Therapy and Logotherapy in previous work (ll), Accept- ance and Commitment Therapy relies primarily on the use of inherent paradox, as opposed to constructed paradox, which is more commonly employed in most paradoxical interventions (6). Although examples of constructed and inherent paradox can be found within the Logotherapy literature, dis- tinguishing the two types of paradox helps to highlight Acceptance and Commitment Therapy's unique contribution to this therapeutic technique. A constructed paradox involves social demand of rule-following which creates a situation in which the individual must either follow or resist the rule (6), and in either case, the effects are most likely beneficial. For example, a couple troubled by very infrequent sexual activity might be explicitly instructed not to have sexual intercourse. This procedure is typically refer- red to as constructed paradox but is not commonly employed in Acceptance and Commitment Therapy for two reasons. First, the focus of constructed paradox is on eliminating symptoms and, even if the technique works, it leaves in place a change agenda with which the problem originated. Second, constructed paradoxes rely on pliance, i.e., social demands or rules that lead to compliance or resistance, which Acceptance and Commitment Therapy views as a potential source of clinical difficulty (6). An inherent paradox is produced by a functional contradiction between the literal and the functional properties of verbal events and primarily involves verbal constructions regarding events not readily rule-governed. In do- ing so, inherent paradox refers to a process that cannot be entirely literal or verbal. The most central inherent paradox used in Acceptance and Commit- ment Therapy is a "rule" about distressing private events: "If you aren't will- ing to have it, you've got it" (6, p. 121). For example, if a panic disordered client is entirely committed to not having a panic attack, the occurrence of even low anxiety is something about which to get anxious. Having anxiety about anxiety has the effect of precipitating even higher anxiety, providing more anxiety to be anxious about. Acceptance and Commitment Therapy does not restrict this view to anxiety. Clients who have long bouts of depres- sion and experience a period of remission may become depressed about the reemergence of depressive symptoms. Acceptance and Commitment Therapy views the inherent paradox as an important therapeutic tool for two reasons. First, repeated exposure to an inherent paradox helps loosen the grip literal 948 W. G. SHARP, ET AL. language has on a client's thoughts, feeling, or behavior by highlighting the fact that literal language is useful in some contexts, but not all. Second, Ac- ceptance and Commitment Therapy's view of psychopathology is an inherent paradox: Trying to change negative content is a major source of the negative content. Acceptance and Commitment Therapy offers radical acceptance as a starting point to a new relationship with symptoms-a common perspective among contemporary behavioral treatments (12). For example, Dialectical Be- havior Therapy (7), Integrative Behavioral Couples Therapy (J), and Accept- ance Based Behavior Therapy for Generalized Anxiety Disorder (8) show sensitivity to the paradoxical effects of direct attempts to control negative cognition and emotion. These newer variants of behavior therapy integrate some of the wisdom in existential and humanistic approaches, such as Logo- therapy.

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Accepted October 4, 2004.