Paradoxical intention in the treatment of obsessive thoughts: A pilot study

Paradoxical Intention in the Treatment Obsessive Thoughts: A Pilot Study

of

By L. Solyom, J. Garza-Perez, B. L. Ledwidge, and C. Solyom

A

RECENT SUMMARY of 12 follow-up studies on obsessive neurosis from seven different countries sets a nonimproved rate at 50%.’ The course of obsessive neurosis frequently entails great suffering, often leading to social invalidism’ and it does not seem to be altered by any treatment other than lobotomy.3 The prognosis of obsessive compulsive neurosis, therefore, is probably worse than that of any other neurotic disorder. A plethora of studies on the effects of different treatment techniques on phobias, sexual deviations, etc., followed the advent of behavior therapy. Only eight studies, however, have been concerned with the behavioral treatment of obsessive neurosis. The majority of these reported on single cases and were less than enthusiastic about the results; 46% of the published cases were rated improved. Because of the absence of a coherent theory concerning the origin of obsessive neurosis, there was a greater diversity of techniques of treatment for obsessive neurosis than among those used in the treatment of phobic conditions. Conceptualization of the symptoms of obsessive neurosis was vague and attempts to apply learning theory to the problem were directed more to the formal aspects of the obsessive symptoms rather than to the content of obsessive thought. Compulsive handwashing, for instance, was viewed as a fKated avoidance response, the origin of which was similar to the futation of the avoidance responses of animals studied under experimental laboratory conditions. Repetition alone, however, is only one aspect of obsessive behavior and also is characteristic of such obviously different symptoms as stereotypies, iterative movements, and the perseveration of responses common in schizophrenia and organic brain damage. Fearful avoidance of certain situations and objects is more characteristic of phobias. The truly characteristic obsessive experience of forced thinking or compulsion to act, with the simultaneous realization of the absurdity of the thought or action; the concurrently held opposing convictions; the pervasive doubts and the endless weighting of the pros and cons are not elucidated by animal experiments. While some symptoms or some aspects of the symptoms can be conceptualized as fixated classical or instrumental responses, an understanding of the total psychopathology of obsessive neurosis in terms of learning theory is missing. This lack of a firm theoretical basis perhaps explains the many different behavior therapies used and also the rather weak results of the treatment of obsessive illness. Though our results following aversion relief therapy of 15 obsessive subjects were promising-73% benefited-the quality and the duration of improvement were much inferior to what was achieved in the aversion relief treatment of phobic conditions.4 After experimenting with a combined aversion and aversion-relief treatment, it was

From Allan Memorial Institute, McGill University, Montreal, Canada. L. Solyom, M.D.: Associate Professor of Psychiany, University of Ottawa, Ottawa, Canada. L. Garza-Perez: Psychiatrist, Monterrey, Mexico. B. L. Ledwidge: Research Assistant, Riverview Hospital, Essondale, B.C., Canada. C. Solyom: Clinical Fellow, Royal Victoria Hospital, Montreal, Canada

_

Comprehensive

Psychiatry,

Vol. 13, No.

3

(May),

1972

291

292

SOLYOM

ET AL.

realized that, in the absence of a coherent, wholly embracing theoretical basis, only a symptom-oriented view could be followed. As a first step in implementing this approach, an attempt was made to study the effect of paradoxical intention on some of the symptoms of the obsessive neurosis. Paradoxical intention was chosen primarily because an important aspect of the psychopathology of obsessions seemed to be the paradoxical nature of thoughts, intentions, and/or activities of the patient, i.e., that he feels compelled to say or do things he dislikes. Contrary or paradoxical thinking may permeate almost any of his activities, perceptions, etc. Horrific temptation (obsessive fear of aggressive or sexual impluses) probably best illustrates this paradox. Here the patient is continually tempted to do something horrifying, contrary to his better judgment, his moral principles, and his true feelings. His sexual or aggressive thoughts are as a rule directed at the wrong person. He has aggressive wishes towards people whom he likes most and feels strongly attrached to people whom he dislikes and who otherwise disgust him. Many attempts to conceptualize obsessive illness have frequently centered around this intriguing aspect of obsessive pathology. Freud’ believed that ambivalence, a simultaneously felt love and hate towards a person, is rooted in the love and hate relationship felt by the child towards his mother during the early stages of development. Pavlov6 explained obsessive symptoms on the basis of the ultraparadox phase, a transitional stage between sleep and wakefulness that was characterized by an animal’s positive response to negative, inhibitory stimuli and negative response to positive, excitatory stimuli. Some learning theorists7 conceptualized obsessive symptoms as the outcome of approach-avoidance conflict or as the result of double reinforcement when a positive approach response becomes also an avoidance response. The common feature is all these theories seems to be the recognition of the paradoxical nature of the obsessive behavior. Independent of the theoretical developments concerning the paradoxical nature of obsessive behavior, different psychotherapy techniques began to employ paradoxical thinking in the treatment of neurotic behavior. The techniques, which run counter to the usual psychotherapy technique and, to some extent, even to common sense, were to ask the patient to practice the undesirable or feared habit or thought. Dunlap’ used negative practice to treat tickers, stutterers, etc., who were instructed to voluntarily tic or stutter. Frankl’ used paradoxical intention to reverse the attitude of the patient towards his neurotic sickness. Instead of asking him not to fear his phobia, he was told to tremble as much as possible. Employing a very similar technique, modification of expectations, Meyer lo had two obsessive patients imagine the acts of which they were most afraid, to handle dirty objects, to swear, etc. In both cases he obtained symptomatic improvement. A similar mechanism appears to operate in flooding or implosive therapy” a recently introduced technique for the treatment of phobic fear. The patient is instructed to visualize an exaggerated version of his phobic experience. For instance, a snake phobic patient is asked to imagine that, on awakening from an afternoon nap, he is confronted with a huge smake who bites his face, his arm, etc. The demand to face a fearful situation in the Morita therapy of Japan seems to employ a similar principle. Common to all these treatment techniques is the requirement that the patient not avoid the fearful situation or escape from the anxiety-provoking thought or event. In the laboratory animal, response prevention has successfully eliminated conditioned

293

OBSESSIVE THOUGHTS

avoidance responses.12-‘4 Also inherent in both the clinical and experimental methodologies is the much simpler process of habituation. Our use of paradoxical intention in obsessive neurosis was based on the recognition that: (1) Widely different theories postulated a paradox mechanism underlying some of the obsessive symptoms. Reversing the patient’s thinking and making the intruding thought the willed one might eliminate the thought. (2) While reducing the multiform manifestations of obsessive neurosis to a fixated avoidance response would be an oversimplification; some symptoms may represent such an avoidance response. Preventing the avoidance response by paradoxical intention might extinguish the symptom. (3) Several treatment techniques had used the principle of deliberate repetition of the symptom with some success. To reduce the effect of such variables as personality, motivation, present living circumstances, etc., which might also influence the outcome, each patient served as his own control. Two symptoms, approximately equal in importance to the patient and in frequency of occurrence, were chosen. Paradoxical intention was applied to one of the obsessive thoughts; the “control thought” was left untreated.

METHODS At the outset of the treatment period, subjects were required to complete the IPAT Anxiety Scale, the WolpeLang Fear Survey Schedule (FSS), and a Social Adjustment Questionnaire for Obsessives, designed In this laboratory. In the last questionnaire, the patient scored his adjustment to work, sex, leisure, etc., on a O-4 point scale. Subjects also replied to a questionnaire which measured on a O-4 point scale the four broad categories of obsessive symptoms: (1) obsessive thoughts, (2) rituals, (3) compulsions other than rituals, and (4) horrific temptations. During the initial assessment, all obsessive thoughts that had occurred at least once during the previous week were noted. Two obsessive thoughts, considered by subject to be of equal strength, were chosen for each patient. Obsessive thoughts expressing aggressive, murderous intent were avoided. The patients were then instructed in the paradoxical intention technique. Each was told that instead of trying to push the intruding, frightening, or useless thought out of his mind, he was to dwell deliberately on the thought, indeed to elaborate and exaggerate it and to convince himself of its validity. The patient with recurring frightening thoughts of going insane was instructed to tell himself: “It is true, I am going insane, slowly, but surely. I am developing many crazy thoughts and habits. I will be admitted to a mental hospital, put into a straight-jacket and will remain there neglected by everybody until I die. I won’t even remember my name. I will forget that I was married, had children and will become a zombie. I will neglect my appearance and eat like an animal.” All patients were also instructed to use paradoxical intention systematically, as often as the thought disturbed them. To each patient, a simple explanation was given about the rationale underlying the treatment. “The nature of obsessions are such that instead of the intended thought, image or intention, a contrary thought, image, or intention comes automatically to mind. The more one tries to avoid thinking obsessively, the more one fails. In order to reverse this process, one must deliberately think obsessively.” During the six week period of treatment, each patient was seen weekly for a l-hour period. They continued to take the same medication (trifluoperazine, diazepam, etc.) as earlier. Other aspects of their neurotic condition were not discussed. Four men and six women comprised the experimental population. Their average age was 3 1 years (range, 22-37). All were chronically ill and had suffered for an average of 9.2 years (range, 4-25). All had previously had psychotherapy and drug therapy. One had had a 4%year lasting psychoanalysis, four had had electroshock treatment at one time or another during their sickness. Course of the disease was steady ln six, had been deteriorating In three, and gradually improving in one. Symptoms, except in two young patients, had not changed in the last year.

294

SOLYOM

ET AL.

RESULTS

Characteristics of the patients are given in Table 1. The group scored moderately high on the IPAT Anxiety Scale (mean, 7.8; range, 4-9 on a O-10 point scale), had few fears of minimal intensity on the Wolpe-Lang Fear Survey Schedule (mean intensity, less than 1, range, 0.4-1.6 on a O&point scale). The prevalence of obsessive thoughts, rituals, compulsions other than rituals and horrific temptations is also tabulated. For each patient, the target and control symptom and the degree of change following treatment are presented in Table 2. In five of the ten patients, the target symptom was much less frequent or eliminated, in three, unchanged. Two subjects failed to apply the technique systematically. One feared that by forcibly thinking of becoming insane, she would indeed become insane. In the other, his obsessive doubt interferred with the application of the treatment. His target symptom was the obsessive rumination that everybody could see that his feet did not touch the ground when he was sitting and, therefore, he looked ridiculous. After applying paradoxical intention to this thought for one day, he stopped ruminating about it. The next day, however, he began to ask himself: “Who am I kidding? Who am I kidding . . . ” and the obsessive thought promptly returned. In one subject whose target symptom was eliminated, the control symptom also became less frequent during the experimental period. There was no symptom substitution; no new obsessive thought replaced the successfully eliminated obsession. Some subjects later reported that after the experimental period they had successfully applied paradoxical intention to other obsessive thoughts.

DISCUSSION

There was an improvement rate of 50% in the target thoughts. Discounting Mrs. M. C. whose control thought also improved, a 40% specific effect can be estimated. The short treatment period (6 weeks) was less than optimal in inducing improvement. Since treatment was restricted to a single target symptom and not to the obsessive condition, a comparison of the results with those following the treatment of the whole of obsessive neurosis is not justified. In a recent study on phobias4 generalization from treated to untreated fears seemed to depend on the number of changes in the treated symptoms. Had paradoxical intention been applied to all or most of the symptoms, the effect may have been more comparable with that reported by Gertz. l5 He claimed that 66.7% of his obsessivecompulsive patients benefited from paradoxical intention. Of equal importance is the choice of symptoms, since improvement in certain symptoms leads to greater generalization than improvement in others. A compulsive handwasher, for instance, may have many other obsessions and compulsions but none are as detrimental to daily routine as his obsessive handwashing. Eliminating this most important source of “secondary anxiety” would facilitate the treatment of other obsessions. Because of the experimental design, the choice of symptom was restricted and a compromise had to be made. Frankl’s9 application of paradoxical intention differed considerably from that used non-specific here. Frank1 felt that, “paradoxical intention . . . is an intrinsically method,” and he treated all kinds of neurotics where a reversal of attitude towards anxiety was desirable. In contrast, the present program of treatment was directed at

37

10 Mrs. S. R.

missing datum.

20

9 Mr. J. H.

*MD,

28

8 Miss J. G.

30

5 Mr. R. D.

19

38

22

33

3 Mrs. E. M.

4 Mrs. M. C.

7 Miss P. D.

30

6 Mr. I. D.

8

22

1 Mrs. D. A.

2 Mr. U. E.

Yes

Steady

18

No

Deteriorating

4

0 0

3 0

2

Yes

Improving

10

1

Yes

Deteriorating

MD 9

2.5 2.5

1.6

0 0

4 3

2.4

0

0

23

8 9

11 28

MD

34

7 1 .o

2

0.5

MD

9

2

17 17

4 2.5

7

MD

MD*

Sandier Self-assessment

0.3

9

7

IPAT

2

2

3

2

1 0

3 4

Yes

Steady

5

4

2

0

2

Yes

Steady

12

1

4

0

0

Yes

0

1.5

4

1

1.9

4

1

0

Yes

Deteriorating

0

Compulsions

0

3

No

Rituals

Social Maladjustment Rating

Horrific Temptations

Symptomatology

3

2

No

Steady

Hospitalized

Obsessive Thoughts

Steady

course of Illness

Steady

25

4

12

Age

Patient

Duration of Illness (years)

SOLYOM

296

Table 2. Comparison

of Changes in Target and Control of Paradoxical

Patient

Target

Symptom

Symptoms

After

ET AL

Use

Intention Control

Changes

Symptom

Changes

1 Mrs. D. A.

“I will kill Caroline”

Much less

“I will kill my husband”

Unchanged

2 Mr. U. E.

“I will stab myself

frequent Much less

“I will die of cancer”

Unchanged

when I see a knife” 3 Mrs. E. M.

frequent Dropped

“I will go insane”

study,

“I jump out from a tall building”

could not apply technique 4 Mrs. M. C.

Eliminated

“I am a lesbian

“I think my husband is

5 Mr. R. D.

“Time

is money.

I

“Mustn’t

Unchanged

Unchanged

40 on highway”

work” “I am losing my hair”

drive less than

20 mph in city or over

must speed up my 6 Mr. I. D.

Less frequent

after my sister”

whore”

Much less

“I will turn ugly”

Unchanged

“I did not concentrate

Unchanged

frequent 7 Miss P. D.

“Things are not in

Unchanged

on what people said”

order” 8 Miss J. G.

“I have to see if the

“After

Unchanged

feel

alarm of my clock “My feet do not

Unchanged

have to clarify

my position”

is set” 9 Mr. J. H.

a discussion I

I

Dropped

from

touch the ground

study, could

when I am sitting”

not apply

“I open my mouth too wide when I am eating”

technique 10 Mrs. S. R.

“Paper in the ashtray will catch fire”

Eliminated,

but

subsequently

“Some patients are

Unchanged

missing armbands”

returned

the symptoms that seemed related to the paradox inherent in obsessive neurosis in order to reverse the trend of obsessive thinking. The changes observed might have arisen because (1) the treatment truly induced an attitudinal change; i.e., the obsessive patient’s fear of loss of control lessens when he recognizes that by effort of will he could bring some of the obsessive, unintended thoughts under control. (2) As Solomon and Wynne, l2 Sidman, Herrnstein and Conrad, ’ 6 Lomont ’ 3 and Baum l4 have demons tr a ted, the prevention of an avoidance response may lead to the extinction of the response. (3) A process of habituation may have led to the elimination of the symptom. These possibilities are not mutually exclusive but may describe the same phenomena on different levels of complexity. There seems to be no contraindication to applying paradoxical intention to aggressive thoughts or nonpermissible sexual intentions. The only patient who used paradoxical intention in dealing with such thoughts benefited from the treatment. Though aggressive thoughts are very common during the course of obsessive neurosis, follow-up studies have reported no evidence that obsessive behavior predisposed to homicide or other criminal behavior.2 There are two obvious advantages to the use of paradoxical intention: (1) therapy can be exercised and, in fact, should be exercised, in between therapy sessions, giving the subject less chance to relearn his obsession; (2) positive, if not optimal results, are usually apparent within the first 2 weeks of the treatment. Thus paradoxical intention,

OBSESSIVE

297

THOUGHTS

alone or in combination with other treatments, may be a relatively fast method for some obsessive patients. REFERENCES 1. Yates, A. J.: Behavior Therapy. New York Wiley & Sons, 1970, p. 160. 2. Goodwin, D. W., Guze, S. B., and Robius, E.: Follow-up studies in obsessional neurosis. Arch. Gen. Psychiat. (Chicago) 20:182, 1969. 3. PoIlitt, J. D.: (Chicago) Natural history of obsessional states: A study of 150 cases. Brit. Med. J. 1: 194, 1957. 4. Solyom, L., Zahmanzadeh, D., Ledwidge, B., and Kenny, F.: Aversion relief treatment of obsessive neurosis. In Advances in Behavior Therapy. New York, Academic, 1969, pp. 93109. 5. Freud, S.: Character and anal eroticism. In Collected Papers, Vol. II. London, Hogarth, 1924. 6. Pavlov, I.: Lectures on Conditioned Reflexes, Vol. II. New York, International, 1941. 7. Farber, I. E.: Response fixation under anxiety and non-anxiety conditions. J. Exp. Psychol. 38: 111, 1948. 8. Dunlap, K.: Repetition in the breaking of habits. Sci. Monthly 30:66, 1930. 9. Frankl, V.: Paradoxical intention: A logotherapeutic technique. Amer. J. Psychotherapy 00:520, 1960.

10. Meyer, V.: Modification of expectations in cases with obsessional rituals. Behav. Res. Ther. 4:273, 1966. 11. Hogan, R. A., and Kirchner, J. H.: Preliminary report of the extinction of learned fears via short-term implosive therapy. J. Abnorm. Psych. 72: 106, 1967. 12. Solomon, R. L., and Wynne, L. C.: Avoidance conditioning in normal dogs and in dogs deprived normal autonomic functioning. Amer. Psychol. 5:264, 1951. 13. Lomont, J. F.: Reciprocal inhibition or extinction? Behav. Res. Ther. 3:209, 1965. 14. Baum, M.: Rapid extinction of an avoidance response following a period of response prevention in the avoidance apparatus. Psychol. Rep. 18:59, 1966. 15. Gertz, H.: Experience with the logotherapeutic technique of paradoxical intention in the treatment of phobic and obsessive-compulsive patients. Amer. J. Psychiat. 123:548, 1967. 16. Sidman, M.: Herrnstein, R. J. and Conrad, D. G.: The maintenance of avoidance behaviour by unavoidable shock. J. Comp. Physiol. Psychol. 50:553, 1957.