Therapeutic Paradox in Family Therapy: A Return to Symptom Prescription ()
1. Introduction
Symptom prescription is an intervention described by the school of Palo Alto in California and has been utilized in a myriad of clinical contexts as a psychotherapeutic tool. There was a significant increase of literature in the 1980s focused on this type of intervention, with it having been forgotten in recent times.
Therapeutic paradox, a synonym of symptom prescription, refers to the seemingly illogical instructions which can be used by the therapist to change family relationships and dynamics. Interventions appear illogical because they represent apparent contradictions to the goals of therapy. These interventions present challenges as the therapist needs to provide powerful arguments to persuade the family to follow the apparently contradictory (and at times, absurd) instructions. Major classes of therapeutic paradox include symptom prescription, restraining and positioning [1].
The focus of the present work is on symptom prescription, a theme which has been poorly explored since the 1980s, which involves solving a “problem” or symptom by prescribing the very behaviour determined as problematic. It is described in the literature as a potential psychotherapeutic technique designed to facilitate symptom reduction in a variety of circumstances, including family therapy. The technique of prescribing the symptom, when adequately applied, is demonstrated to be effective in cases in which more standard treatments have proved unsuccessful.
2. Methods
The authors conducted a brief narrative review of the available English literature. Various databases were utilized including PubMed and GoogleScholar. Of the search conducted on the PubMed database 31 articles were found utilizing the search terms symptom prescription or paradoxical intervention associated with family therapy. Of the search, 8 articles were chosen as most relevant and focused on the explored theme. The authors opted to expand the search using the GoogleScholar database, with 9 articles chosen due to their relevancy. Relevancy was determined by the language of the article, focusing on the type of intervention investigated as well as its application in the domain of family intervention. Of the articles chosen, solely 3 were written after 2010 with most of the literature produced in the 1980s.
3. Discussion and Commentaries
Symptom prescription is a peculiar technique that is thought to have been first proposed as far back as 1650. It manifests itself as paradoxical form of intervention, as it is “contrary” (para) to “received opinion” (doxa), thus abandoning any form of what is deemed initially as “common sense”. This technique places into practice a contradictory principle, by which “things get better when you try to make them worse” [2].
Various pioneers in the domain of family therapy have contributed to developing the paradox technique, a powerful therapeutic tool in the field. Of note is Gregory Bateson, who studied verbal and non-verbal communication of families in which one of the family members was diagnosed with schizophrenia [3]. His team introduced important concepts in therapy such as: communication, meta-communication, double-bind, circular mode and paradox [4]. Another prominent systemic author proclaiming the effectiveness of symptom prescription when applied adequately was Paul Watzlawick, author of Pragmatics of Human Communication, with him defining paradox as “a contradiction that follows correct deduction from consistent premises” [5] [6]. Other therapists explored the application of paradox interventions in which a member of the family battled anorexia nervosa. One of the potential aims of symptom prescription is to provide the family elements the capacity to pursue individualization and separation through the provision of a creative solution to complex issues that arise within the family system.
This type of intervention gained popularity in the 1980s, a time when a significant shift in the psychotherapeutic context with growing interest and validity of the cognitive-behavioural intervention, which was quickly gaining traction, whilst the psychoanalytic tradition was subsequently losing its power-hold on the standard therapeutic intervention [7].
The therapist uses powerful rationales and arguments to encourage or instruct the patients to perform their symptoms, and even aggravate them. Therefore, it is the task of the therapist to elicit the cure from within the patient [8]. According to Watzlawick, in The Language of Change:
We experience symptoms as inhibitions or as impulses outside our control, and in this sense totally spontaneous. […] For if the deliberate attempt to be happy causes depression, and the effort to fall asleep keeps us awake, it stands to reason that the voluntary, deliberate performance of seemingly uncontrollable behaviours should deprive them of their spontaneity [9].
For example, a couple requesting treatment in order to reduce martial conflicts may be instructed to continue to fight in order to resolve (un)identified underlying issues and eventually progress towards a more harmonious family life [8].
In fact, if we reflect on this idea, we can identify that the use of symptom prescription exists in a more conventional, widespread and empirical form through the application of the commonly denominated “reverse psychology” which is typically applied in the discipline of children and adolescents. For example, this may be applied by a parent insisting that a screaming child continue to scream so as to thwart a dramatic tantrum. Another example that parents may employ is praising and incentivizing the symptom, such as inconsolable crying in a child, by saying that “crying is good for the soul.”
Descriptions of the psychotherapeutic technique of paradoxical symptom prescription have appeared under various descriptions in different schools of psychotherapy, including negative practice, paradoxical intervention, massed practice, paradoxical intention, implosion, symptom scheduling and symptom prescription [10]. In practice, any component of the symptom complex can be prescribed, including the cognitive, affective, behavioural, contextual, relational, attitudinal, and symbolic components. [10]. Paradoxical interventions themselves can be divided into two categories: compliance-based strategies and defiance-based strategies [11]. Compliance-based paradoxical strategies exert change by the client attempting to comply with a therapeutic directive, whereas defiance-based interventions work because the patient rebels against the therapist's directive [12].
Table 1. Types of paradoxical interventions [13].
Paradoxical Interventions |
Asking members of the family to do something that appears to be in opposition to the goals of treatment. |
Symptom Prescription |
Family is requested to continue to perform or even exaggerate and aggravate the symptom. It may be compliance based (when the goal of the therapist is for the family to comply with the suggestion) or defiance based (when the therapist wants the family to defy the suggestion). |
Restraining Techniques |
Members of the family are warned of the dangers of change and restrained from trying to do so. Applied in families ambivalent to change. |
Positioning |
The therapist amplifies or exaggerates the family’s explanation of their problem, inciting disagreement from them. |
A symptom is a form of communication [8] and symptom prescription involves changing the form and/or context of the symptom that is to be the aim of intervention. Form involves requesting that the patient exaggerate the symptom or express it in a different social context, whereas context deals with deliberately enacting the symptom [7]. Good rapport and a strong therapeutic relationship are a basic requirement for ensuring that therapeutic prescriptions are carried out. This is important as a method of demonstrating that the patient has voluntary control of the behaviour in question.
The underlying basis for the effectiveness of this particular technique is that one engages in behaviours for a reason, which is typically to meet a need. In prescribing the symptom, the therapist helps the patient comprehend this need and determine how much control they have over the symptom, thus paving the way for change. In other words, paradoxical interventions (See Table 1) are designed to alter the self-sustaining nature of a symptom by interrupting the reinforcing feedback loops that maintain it through engaging in opposite behavior [14]. According to this logic, a person who can voluntarily produce the symptom can also reduce it voluntarily.
According to a 1980 work, the use of symptom prescription has been described to have three principles described by Milton H. Erickson: “meeting the patient within his frame of reference, using the patient’s own behavior and understandings to make small therapeutic modifications, and eliciting the cure from the patient in a manner that allows the opportunity for patient-initiated change” [10].
The construction of the symptom prescription can be simple or involve more complex elements with symptoms being broken down into constituent elements and subsequent prescription of these. The prescription may be ritualized, for example, by prescribing them in a fixed sequence or by laying down that whenever event X occurs, the client is to have the symptom. The therapist asks the patient to deliberately have the symptom and family members may be recruited in order to encourage or reward the behaviour. An example of a simple paradoxical prescription includes prescribing that a depressed patient “be more depressed during the next week”. There are many possible prescriptions and combinations that can be constructed for any identified symptom [8]. A word of warning should be said about the application of these techniques, in which inexperienced therapists usually find both the delivering of paradoxes and the impact on the family quite difficult to manage, thus caution should be exercised when opting for this intervention [4].
If we reflect upon what has been described, it makes sense to include a word on the importance of power dynamics in the family system. This demonstrates another sphere through which symptom prescription exerts its effects, especially in terms of the family system, which is not always so clearly described in the already sparsely available literature, but which makes sense in the clinical application of this technique.
When a patient seeks aid from a therapist, it is namely to resolve a perceived problem that is negatively affecting their lives. There is an underlying assumption that the patient brings a symptom (or problem) to the therapist and that the onus of the cure or resolution rests with them. However, through symptom prescription, the power of the symptom in question becomes displaced. It shifts the focus, paradoxically, away from the symptom removing the weight and importance that this may carry for the family in question. In other words, through prescribing what the family identifies as the problem the therapist diminishes the perceived severity or significance that this has on the family system. Through the prescription, the symptom also loses power as a “weapon” that can be utilized by any element in the family dynamic. The power of this therapeutic technique in family therapy is that it permits an automatic, instantaneous and self-evident reformulation of the power dynamics in regard to the symptom and the person utilizing it. At the same time, as was previously described, it acts to remove the therapist from the forefront of the equation.
Applying this to the above example of the couple who seeks therapy due to constant bickering; by prescribing more conflict, the therapist places the onus of resolving the situation within the couple dynamic and removes the power that the symptom (i.e. conflict) possesses over this interaction. The first element of the couple may verbalize the motive for seeking therapeutic aid due to conflict with the second, thus, through prescribing the very complaint presented, the therapist displaces the responsibility that was initially handed over to them by the patient, as well as disarming any possibility of the maintenance of the symptom due to secondary gains. If the patient maintains the conflict, they are simply adhering to the prescription, if they reduce the conflict it demonstrates that there is control over this behaviour, and although failing to adhere to the prescription, family harmony can be attained. This reflects the saying “damned if you do and damned if you don´t”, wherefore in a therapeutic double bind the person is “changed if they do and changed if they don´t” carry out the prescription [15]. When the couple gains awareness of these circumstances, it represents the first step towards change in which they are forced to reflect on what is really happening when they fight.
The use of the paradox in appropriate cases can produce positive outcomes benefiting the affected family by permitting a more workable and functioning system whilst placing the onus of this positive effect on them. The impact of positively connoting the symptomatic or distressing behaviour patterns may take much of the guilt and anxiety out of a fraught and emotionally draining situation [16].
According to Selvini, “It is a creative solution for long-term illnesses” [17]. In this manner, the paradox is a powerful tool for family therapy, existing as a creative and critical solution, in which some humor is needed, to intervene in a myriad of problems thus effectively facilitating therapeutic change. This technique, although not at the forefront of options, can be utilized when other techniques have failed. One of the Achilles’ heels of this type of intervention, according to Watzlawick, is the necessity of successfully motivating someone to carry out the instructions, which may prove challenging [15]. According to the only studies published to test this technique in family clinical cases [4] [8] the results have been shown to be satisfactory in reducing the symptomatic behaviour targeted with positive effects on the family system.
4. Limitations and Shortcomings
The available literature on therapeutic paradox is rooted in publications of the 1980s with few recent publications. This causes implications in terms of structured analysis of the theme, as well as relevancy and applicability in modern times. Additionally, most of the literature claiming the effectiveness of this intervention is anecdotal in nature and derives from uncontrolled case studies. These limitations do, however, offer an opportunity that the authors have strived to fulfill in part by attempting to revive interest and knowledge about this peculiar technique and its application in family therapy. Further attention should be paid to atypical therapeutic techniques so as to increase the therapist´s arsenal when treating potentially challenging family dynamic issues.
Concluding Remarks
Prescribing the symptom is a form of paradoxical intervention implemented to bring about therapeutic change through prescribed maintenance of the problem. Symptom prescription is a technique of psychotherapy that can be used with a diverse group of patients, ranging from individual intervention to intervention in family units. Using symptom prescription, the patient can discover and demonstrate to themselves that they can make the changes that they procure from therapy.
The application of this technique can be used directly as a prescription in itself; however, the communicational use of the technique is also a powerful tool which can be used in order to confront patients with certain behaviours and incentivize the need for change, which is the ultimate objective of therapeutic intervention. Recent literature on this intervention is scarce, thus offering an opportunity to further study modern implementations of therapeutic paradox, which appears promising in a myriad of family contexts.
Practitioner Points
Symptom prescription is a psychotherapeutic technique which can be applied in a variety of clinical situations, including family therapy.
Although not a technique to be applied indiscriminately, this is a tool to consider in special cases where conventional interventions have not been successful.
The literature is scarce in regard to the application of symptom prescription in the context of family therapy, but the available literature is promising in this regard.
Conflicts of Interest
The authors have no conflicts of interest or disputes to declare.