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Melissa, a graduate student in psychology, stood 4’11” and weighed about the
same as an NFL linebacker. “I guess I really don’t have a typical eating
disorder,” she said blushing. “I mean you won’t really find a description of my
addiction in the DSM.”
Melissa’s chart indicated that she was attending an
Overeaters Anonymous group on a regular basis and had completed a course of
treatment at two well-respected centers.
I looked up from the chart. “Tell me about your
addiction.”
“Well,” said Melissa, sheepishly shrugging her
shoulders. “I don’t eat a perfect diet. Who does? My drug of choice is
cupcakes.”
Confessions of a confirmed cupcake
addict
The client went on to explain that her “drug of choice” was a
famous brand of chocolate cupcake. There was no need for a dealer since she once
could purchase her cupcakes at virtually any food or convenience store in the
nation.
“How many cupcakes do you eat in an average day?” I
asked.
“Oh, that’s easy,” she remarked. “I’ve been keeping
a baseline for the past several months.”
“Gee,” I thought to myself, “Baseline and DSM. This
client knows the lingo better than the average addiction professional,” though
to be sure in this case her knowledge certainly wasn’t power.
“The mean number of cupcakes I eat is 54 a day; the
range is from 39 to 68.”
Since Melissa had a wealth of knowledge about our
field I asked her if she was familiar with the technique of guided imagery and
creative visualization. I fully expected that Melissa would answer in an
affirmative manner and then go on to explicate the merits of these strategies.
She did not disappoint me. She went on to recount an early study that I was
familiar with, published in Research Quarterly, that clearly
demonstrated the efficacy of mental imagery on basketball
performance.
Next I had her close her eyes and I put her through
a rather typical guided imagery session in which I had her visualize herself
going through several days cupcake free.
After she opened her eyes I told her I was going to
give her specific directions. Post- guided imagery, psychotherapeutic homework
if you will.
More cupcakes? This really does change
everything
Melissa assumed that I was going to tell her to stay away
from cupcakes.Practice abstinence. If this were Melissa’s initial course of
treatment, I would have done just that. Nevertheless, common sense wasn’t
working — it was time for some uncommon sense.
I said, “Look, you normally wolf down about 55
cupcakes every day. But to make certain the visualization is effective I want
you to step things up a little and try to eat at least 75 cupcakes per
day.”
Melissa balked at the idea. “But I’m not sure I can
eat that many in a day,” she told me.
I insisted that she try and also told
her to switch to another brand of cupcake. I now had the client in an
interesting double bind. That is to say: If Melissa’s cupcake intake drops like
a rock or she quits altogether then I can merely explain it away by explaining
that the guided imagery caused the change. If, on the other hand, her cupcake
eating escalates, there is no reason for despair and certainly no reason to fear
that the treatment is a failure since she is merely following my directives.
The solution to the problem is the
problem
Paradox is excellent for eliminating manipulative or genuine
feelings that the treatment isn’t working since paradox is really prescribing
the problem with an exaggeration or a twist.
Most experts agree that paradox
has its roots in the work of logotherapy pioneer Viktor Frankl and habit control
specialist Knight Dunlap. In recent years, the technique has been popularized by
Jay Haley and the late great, Milton H. Erickson (not to be confused with Erik
Erikson, who popularized the eight psychosocial stages of life
development).
Here are some vest pocket ideas to jump-start your
creativity in regard to paradoxical interventions:
- A mother with a teenage son who played his stereo
too loud was instructed to tell her son that she suddenly began to love his type
of music. Therefore, she began to turn the volume up even higher, but would
always adjust the equalizer or tone controls (i.e., remember to prescribe the
problem with a twist) until her son protested that the music was too loud and
could damage his speakers. He insisted that the volume should be lowered.
(Caution: Earplugs might well be appropriate for moms given this
assignment!)
- A client with a dual diagnosis ofalcoholism and paranoid schizophrenia refused to talk to the
therapist believing that the therapist’s office was bugged by the FBI. The
therapist agreed and then exaggerated the problem stating that it was her belief
that the office was bugged not only by the FBI, but also by the Secret Service
and CIA as well. She insisted that the two of them conduct an extensive search
for any surveillance devices. Finally the client accused the therapist of being
paranoid and suggested that treatment should commence!
- A very religious woman with severe depression was
told by her pastoral counselor that it was God’s will that she be depressed. The
counselor thus told the woman to take an hour a day where she merely sat in a
room and tried to become more depressed than usual. The woman returned only to
report that she was unable to remain that depressed for such an extended period
of time.
Read this before prescribing your first
paradoxical assignment
Paradoxical assignments are a little like
risky surgery: Such interventions can be lifesavers; nevertheless, they are not
always appropriate. In fact, if used incorrectly a paradox could prove
deadly!
A cocaine addict, for example, could not ethically
be told to use more cocaine! The act could result in a stroke or even sudden
death. Since many addictive behaviors and substances themselves are so dangerous
it behooves the counselor to use paradox in relation to dysfunctional behaviors
unrelated to using.
Six salient suggestions for using
paradox
Here are some suggestions for implementing
paradox:
- Never use paradox with suicidal or homicidal
clients.
- Never advise the client to escalate an addictive
behavior that could hurt the client or those who come in contact with the
client.
- If you are a practicum student or neophyte
practitioner, always check with a supervisor prior to prescribing
paradox.
- Ethical guidelines have become quite strict. If you
have any doubt that a paradoxical intervention could violate ethics then don’t
use it.
- Some ethical guidelines delineate informed consent
and disclosure guidelines that clearly stipulate that a client has a right to
know why you are prescribing any assignment. Some practitioners who practice
paradox insist that this weakens the impact of the paradox, though I would
suggest that it generally does not negate its total impact.
- Try traditional strategies before resorting to
paradox.
How paradox worked on me
I shall
conclude with a personal anecdote that attests to the efficacy of this
technique.
Many years ago there was only one alcoholism-prevention training
program in the town I lived in and it was very expensive. Since my employer was
footing the bill for the training, each employee needed to send a request form
to be accepted. For several years, I submitted one each week and was turned
down. Again and again, my supervisor reminded me that I had a huge caseload of
clients who needed my services and there just wasn’t time for me to attend the
training.
I had first discovered the work of Haley and
Erickson and decided to give their ideas a try. I immediately sent my supervisor
a memo and told her that I changed my mind about the alcoholism training and
that she should not be getting any requests from me. Several minutes after she
received the memo she marched out to my desk and yelled, “You will report to
alcoholism training first thing Monday morning and frankly I don’t care whether
you like it or not. Is that clear?”
Clear and ready for take off!
Dr. Howard Rosenthal is the Program Coordinator
of Human Services at St. Louis Community College at Florissant Valley and the
author of the Encyclopedia of Counseling and the first ever Human Services
Dictionary. His Web site is www.howardrosenthal.com.
This article is published in Counselor,The Magazine for Addiction
Professionals, August 2003, v.4, n.4, pp. 56-57.
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