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.”

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:

1. Never use paradox with suicidal or homicidal clients.
2. Never advise the client to escalate an addictive behavior that could hurt the client or those who come in contact with the client.
3. If you are a practicum student or neophyte practitioner, always check with a supervisor prior to prescribing paradox.
4. Ethical guidelines have become quite strict. If you have any doubt that a paradoxical intervention could violate ethics then don’t use it.
5. 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.
6. 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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