Monday, August 9, 2010

Paradoxical Intervention

Intervention is a term used in therapy. It refers to a planned action on the part of the therapist which is done with an intended outcome in mind. The success of the intervention is evidenced by whether or not the planned and specific outcome is achieved.

Most people know of term 'intervention' in therapy from the television series regarding the confrontation of an addicted person by friends and family with a view to having them accept going into treatment.

Fewer people know of 'paradoxical interventions' as a therapeutic tool. They are clearly a standard part of 'strategic therapy' from the Eriksonian School of Family Therapy. Individually everyone who has raised children has probably done them at some time without necessarily knowing this term.

In a paradoxical intervention the therapist tells a person to do something with the intention of achieving the exact opposite result. The most extreme example is the therapist telling a suicidal patient to kill themselves with the result that the patient becomes non suicidal.

I've used this 'technique' on many occasions. It's dangerous naturally. However it's even more dangerous not to use a 'paradoxical intervention' in an appropriate situation. The trouble is that increasingly our society 'faults' the active therapist while it rewards the passive therapist. Doing nothing is often what incompetent and negligent people do without consequence. However increasingly if a person takes an action with competence and care and that action doesn't result in the planned outcome then that person can be faulted.

I had a colleague who left a trail of deaths behind them because they always rushed to rescue chronically suicidal patients causing the same patient to up the ante the next occasion and other patients of theirs to compete for attention with increasing suicidal behaviour. Everyone except the few of us who were more experienced saw this person as caring. This really was an example of killing with kindness.

When I was delivering babies I had to use 'high forceps' to extract a 'stuck' child. I did without negative consequence to the baby. The potential risk is that high forceps can cause brain damage to the child. If I had not used high forceps and referred the child for caesarian section with medievac the mother and child quite likely could have died but for sure the child would have died. I was alone in a rural situation without anesthesia and only a nurse assistant. Caesarian section might have been possible but I was less experienced with c/section than I was with forceps. Even then I'd only assisted in a couple of high forceps and done none myself. It was about the same with c/section.

I knew all this as I applied the high forceps. Typically I could not form a committee to distribute accountability and diminish my personal risk, or consult a judge so that I could in future protect myself. Lawyers were not on call in those days. There was a telephone at the other end of the nursing station but none at the bedside where all this was happening so I didn't think it a good idea to leave and have a group 'huddle' over the phone. I did what I thought was best for the mother and child and am glad I was right.

I don't like that armchair quarterbacks, the legal system, sit in judgement of front line trench troop decisions with all their pretension and superiority. I saved mother and child. I didn't get a medal. I believe that many of my colleagues would not take the risk at that time. Indeed I was the only Canadian doctor who volunteered to work in that isolated region and the two other doctors who covered the north with me had to be recruited from other countries. There'd been a recruiting campaign for 2 years a before I accepted the position and my presence alone ensured dramatic reduction in morbidity and mortality in the region. I was not rewarded for that stupid business decision, going where the medical legal risks were great and the pay was much lower than big city hospitals with all their resources.

Adolescents and some borderlines will say that they are going to kill themselves. These are not 'depressed' patients who have not been given the right pharmaceutical elixir despite my pharmaceutical rep colleague's insistence that they have a 'clinical depression' and their suicidalness is a product of 'untreated depression'. Suicide is commonly an acute situational reaction and for many it's a kind of 'social terrorism'. It's manipulative. This 'fact' is increasingly being denied as the behaviorally disturbed person is given the fancy label of "rapid cycling bipolar' to explain why when the boyfriend left them they threatened suicide and then when the boyfriend or girlfriend came back their suicidality stopped.

"Mood disorder" psychiatry is the psychiatry of 'symptoms" and it denies 'external events" and generally acts as if patients brains function in a vacuum like the laboratory rats. This approach is beneficial if part of a biopsychosocial model but alone it's literally more insane than the behaviour of the patients it's treating which might make it work in a twisted paradoxical way.

"My girlfriend left me. I'm so upset."

"No. Your neurons are unhappy and that's why your girlfriend left you."

So imagine a person who is chronically manipulative and attention seeking who may have actually been trained to be suicidal by the positive attention that threatening suicide brings. This person may have 'learned' suicidal behaviour as a product of an initial suicide while depressed. Indeed the suicidal behaviour may have become 'compulsive' and whereas at first it was because the boyfriend or girlfriend left them it's now because the individual broke a finger nail or someone didn't 'respect' them.

A borderline personality disorder manipulation might be to threaten suicide as a sociopath might threaten homicide. Women historically could get more attention by this mechanism than they might by threatening homicide which was 'unfeminine'.

Now couple suicidal threats with anti authoritarian behaviour. Here is the result.

"I'm going to kill myself".

"Good, I'm telling you to kill yourself."

"You can't tell me to kill myself, I said I'm going to kill myself first."

"It doesn't matter. If you kill yourself now it's going to be because I told you to kill yourself."

"Well, I'm not going to kill myself then."

"Suit yourself. "

This is essentially a replay of a successful paradoxical intervention that I did repeatedly when working with adolescents. Now that I've shared it it will probably not work. Much of the art of psychiatry as opposed to the 'science' was knowing such 'tricks' of the trade.

But consider, if the patient was schizophrenic I could say to them 'don't kill yourself' and because they were psychotic they would interpret that I really wanted them to kill themselves. Yet people think that being 'politically correct' and looking good for the media and the soundbites is good therapy. It kills schizophrenics. The only thing to do with a suicidal schizophrenic is treat the psychosis, protect them from themselves and distract them. Suicidal schizophrenics can be thinking of suicide all the time but commonly they are only acutely suicidal for very brief periods. Psychiatric emergencies work amazingly well for schizophrenics whose medication needs to be adjusted upwards and suddenly the suicidal behaviour will go.

Unfortunately some people treat all suicidal people as schizophrenics thereby protecting themselves and limitting their 'solution' to 'more meeds' when in fact the 'paradoxical intervention' noted above would be indeed the 'treatment of choice."

Addicts are commonly suicidal. Alcohol and drugs cause the brain to be changed and induce psychosis. The treatment in this case is to treat the primary intoxication. Every ER doctor routinely sees Friday night drunken or drug addicted suicidal patients who no longer intoxicated in the morning are safely sent home. What is wrong is that anyone who becomes suicidal or homicidal under the influence of alcohol or drugs should be diagnosed as having an addiction to drugs or alcohol if they drink or do drugs again after that. Non addictive people would not eat asparagus again if it caused them to break out in suicidal or homicidal behaviour and put them in a hospital. By definition a person who becomes suicidal or homicidal while intoxicated suffers from the disease of addiction if they persist in drinking or using drugs.

A paradoxical intervention I used successfully recently was to tell a person to stay at home under the care of their parents. This was a 20 year old who was 'freeloading' and thought themselves rather 'smart'. They had entitlement. The single mother wanted the son to be out of the home and working but the son literally didn't want to 'grow up'. So I told him he shouldn't leave home because he wasn't mature enough and he needed to stay home because he was still a child. I told his mother this too and the boy made plans to move out and get a place and job within the month.

I had the pleasure of studying under Jay Haley and he wrote the book Uncommon Therapy describing many examples of paradoxical intervention that Dr. Milton Erickson applied in his work.

It was standard practice in marriage therapy where a couple was not having sex to tell them not to have sex before the next session with the consequence that more frequently than not they'd have sex because whatever reason they'd not been having sex was no longer present and together they could 'collude' against the therapist.

Understanding a particular event in the context of a 'system' such as a family or community is more rigorous and difficult than simply giving a pill and treating a symptom. Ignoring the context, ignoring the family and being a 'good breast' giving a 'nurturing pill' is even more acceptable than 'withholding' a drug of abuse from patients. Rarely will a doctor get in trouble for giving valium, xanax, or clonazepam or ativan. Yet addiction doctors following up on deaths on methadone found that the principal cause of death in their study was the benzodiazepines being given not by the addiction doctors who were prescribing methadone but by the psychiatrists who were apparently treating 'anxiety'.

I could never explain the complexity of decision making in the trenches to someone who has never been there or was there in a different war in a different world. I'm getting old and realizing that increasingly the whole of psychiatry and medicine is rapidly 'dumbing' down. Even as wars are being fought by opinion polls so increasingly medicine and psychiatry are being judged on 'popularity' scales.

I reduced suicide rates immensely by utilizing all manner of techniques and approaches which today I'd be loathe to do because they 'wouldn't look good'.

I remember a woman who was acutely suicidal and the administration couldn't find a bedside nurse to assist us one night. So I simply refused the patient cigarettes by explaining that I couldn't let her chronically kill herself with cigarettes if she was acutely suicidal but that if she was not suicidal I could let her chronically kill herself. As her nicotine addiction kicked in she demanded cigarettes and in exchange I asked her to write down all the reasons for living and prove to me that she wasn't just saying she was no longer suicidal to get a cigarette. She did. All of the thinking thad had gone into figuring ways to kill herself in hospital now was employed to convince us that she was not suicidal. In the process she really did convince herself. She lived. Myself and the nurses hadn't thought she'd make it through another night. The administration would not have been accountable for her death. Indeed administrations are usually set up to work safely in the world of 'protocols' and never deviate from their safety and certainty. It doesn't matter if a patient dies. It's paramount though that the 'protocol's' were correctly followed.

I lost one case I regret but then she'd attempted suicide 50 or more times and more times in hospital than community and the fact remains that the more attempts at suicide statistically the greater risk of a person 'accidentally' killing themselves when they weren't really intent on suicide. Many people appear to be suicidal but choose and set up rescue with redundant contingencies to confirm that it really wasn't a "serious' attempt.

Unfortunately I've seen patients, especially children and adolescents, who died with a 'suicide gesture', taking several of the pills of their parents only to have the pills be unlike aspirin where it takes many to kill something else with a very limited window of safety.

Just as doctors are 'cherry picking' patients to protect themselves from litigation or dirty patients or really complex sick ones increasingly the 'system' rewards doctors who merely 'look' good.

My popular colleague who was always 'overtly' caring left a trail of bodies behind him/her because s/he was always dramatically rushing to 'rescue' the suicidal patient only to have that patient increase the ante with each attempt and other patients of his/her competing to get attention. Dead patients don't complain and it's just 'too bad'. He/she was always so 'broken up' too. Meanwhile I was the 'toughlove' doctor who wasn't popular but my patients had long stopped killing themselves. I'd had suicides early in my career and later worked the psychiatric emergency and intensive care wards where I learned how not to 'enable' suicidal behaviour.

One of the techniques I used then with success was paradoxical intervention.

Today I don't use a lot of my training or experience because the only 'safe' way to practice psychiatry is the politically correct way. Increasingly I want to cherry pick patients to get the highest pay for the least work. I've never paid attention to the 'business of medicine' but now as medicine and psychiatry is no longer called a 'calling' but rather a 'business' and patients are 'customers' rather than 'patients' I find it's easiest to skip the complex stuff and limit myself to things I could explain to lay people in sound bites or on talk shows.

Though paradoxical intervention works and is a standard part of good psychiatric armamentarium it's really not as easy to explain as say, massage, even if massage doesn't work for say, appendicitis.






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1 comment:

Tara Sims said...

I discovered this blog post while researching for a paper I am writing on paradoxical intervention.... I found this post very informative, entertaining and intriguing. I hope to explore other blog posts of yours in the near future. Thank you.