by Martha Stark, MD / Faculty, Harvard Medical School


What is the role of paradox in the therapist's repertoire of optimally stressful, anxiety-provoking but growth-promoting interventions.


As we know, it is by way of immersing herself empathically in the patient's internal experience that the therapist comes to appreciate the patient's investment in being the way she is. 


The therapist can now do one of two things. 


The therapist can offer the patient an empathic intervention that will demonstrate understanding acceptance and will enable the patient to feel supported and validated.


Alternatively, the therapist can offer the patient not an empathic intervention but a paradoxical intervention – in which she suggests that she knows the patient might well be so invested in maintaining things as they are (so invested in her defenses) that she might ultimately choose not to change.


By way of examples:


To a 35-year-old patient who complains nonstop about how much she hates her job but never does anything to change her situation: "Although you dread going to work each day, your job does (as you say) provide you with a certain degree of financial security. I think I am beginning to understand that, at this point in your life, your feeling is that it simply may not be in the cards for you to change jobs. Maybe it was just meant to be that you continue in your current job for the rest of your working days."


If the patient is made angry by the therapist's paradoxical intervention, then the patient's anger may well empower the patient, may well provide the necessary motivation (or impetus) for her to change – if only to prove the therapist wrong!


Or, "I think I am beginning to see why you feel that you cannot afford to trust anyone. Based on what you're telling me about the numbers of times your trust has been betrayed in the past, I can now understand why you feel that you may never find a partner. Although it means being alone for the rest of your life, at least you'll know that no one will ever be able to hurt you ever again." 


Or, to a 45-year-old man married for twenty years: "You hate it that your wife abuses you in all the ways that she does, but then you begin to think about how old and tired you feel and decide that perhaps it is too late, the time to have left may already have come and gone."   


The therapist uses her "empathic understanding" of the patient to offer the patient a paradox.


When the patient clearly signals that she does not experience herself as being in a position to change, the therapist takes her at her word, accepts it, offers her no resistance. In a paradoxical intervention, the therapist does not challenge the patient to take responsibility for her life. Rather, the therapist suggests that, based on what the patient has been saying, the therapist can now understand why the patient might indeed choose not to change.


It is crucial that the therapist who offers the patient a paradox not simultaneously express disappointment in, or disapproval of, the patient; rather, the therapist must offer the patient a dispassionate statement of "fact" – based on what the patient has been saying. 


The therapist gets it, understands it, has no problem with it, is willing to make her peace with it.  It's no skin off her back. 


The therapist must not need the patient to change.


Finally, to a patient with all sorts of unrealized potential who protests repeatedly that she can't do anything differently: "From what you're saying, I think I am now coming to understand something I had not previously fully understood -- namely, that you may really be doing the best that you can."


Note that even as the therapist is seemingly letting the patient off the hook, the therapist is also highlighting the fact that it is the patient who has chosen not to do what she knows she would need to do in order to get better. It reminds me of a poster from the 60s that said: Not to choose is to choose.


In other words, even though the patient is not being held accountable for moving forward in her life, the patient is being indirectly held accountable for choosing to fail – in essence, she is being empowered.


In sum, empathic understanding of where the patient is in the moment enables the therapist to offer the patient either an empathic response that will enable the patient to feel understood or a paradoxical response that will force the patient to take ownership of the choices she is continuously making about how she lives her life.