Psychotherapy is an effective treatment for psychiatric disorders including anxiety and depression [1]. American Psychiatric Association (APA) recommends use of psychotherapy as an initial treatment for mild to moderate depressive disorder and as an add- on treatment for moderate to severe depression [2]. While there are a number of treatment manuals and protocols developed for various forms of cognitive behavior therapy, the strengths-oriented strategies are based on more general counselling and psychology principles [3-5]. Paradoxical psychotherapy derives and builds upon these concepts and this article provide a general framework in the context of our work on inpatient paradoxical therapy.

Introspective deduction

I was struggling to stay awake after a poor night of sleep due to Aleeza, my two-year-old angel-faced devil struggling with cough and cold. It was my second day at work with this new Health care System. I also had a sore-shoulder. To make matters worse I did manage to fry a puri (an Indian snack) only to burn my hand with the splash of hot oil.

The pain helped me stay awake at work. I was getting pulled off in so many directions at my new job within a matter of few minutes. These periods of chaos were punctuated with periods of relative calm in which I would see new patients in walk-in clinic. I would assess their problems and give them my advice as to how to manage their symptoms better or ease their psychological burden. I had a big one of my own.

Marie who is in her early fifties came in to seek help. She has been struggling with her medical problems that include ulcerative colitis, high blood pressure and back-pain. She lost her 17-year-old cat recently that tipped her over into depression. She is tearful and sobbing. She conveys her distress and hard time that she has trying to stay composed. She does seem resilient.

I am trying my best to stay focused, helpful and appear attentive. She looks at my hand and then my face, pauses momentarily and remarks, “my goodness, what did you do with your hand?” the adhesive covering that was hiding the burn had come off.” “It got burnt”, I reply with an ease and no hesitation. I guess it was easier to focus on my burnt hand than her problems.” Does it hurt?” “Yes it does”, I remark my distress.” “I know it must hurt a lot. What are you using for it?” “An antibiotic ointment”, I reply.” “No, use this Olay… ointment. Trust me. It will help you. My sister had same thing and it healed in two days.”

Suddenly the dynamics of the interaction had changed; tables had turned. She was no longer tearful. She was a lady with in good composure who was empathetic and giving me her expert advice. She seemed to have found her strengths and did not seem as bothered as she was when she came in. I did assess her symptoms, gave my opinion, prescribed some medications and documented my assessment of hers. I gave her advice as to how she could handle her symptoms/distress better and seek our help, set her up for follow- up.

I knew that what had transpired in that session had helped her find her strengths back. She left confident and a lot better than what she had come in. When we see people in distress and we have the ability to help them, we may tend to forget our own problems or deal with them better. Sometimes crisis outside of us helps diminish our own crisis.

Paradoxical therapy treatment matrix

•Guided assessment to list Patient strengths [5,6]:

The guided assessment aims to enlist patient strengths that can be used in real life situations, role play or imagined exposure to help enact scenarios and improve coping skills. The assessment looks into various life domains like:

Education: how far in school/college did you attend?

Degrees /diplomas?

Work history

Current job:

How many jobs have you had and how long? list each one:

Hobbies and interests:

Technical/vocational training:

What type? How long?

Where did you grow up?

How was peculiar about your upbringing/ growing up?:

Any Sports/Games you play?:

What are your Special attributes?:

What are your strong points?:

List your strengths in the areas of values, abilities, Family life, culture, Religion and Spirituality:

What do you need to improve?:

•Paradoxical therapy structure: Various patient strengths are evaluated and then matched in a way that patient get a chance to utilize and improve upon their strengths [6].

•Paradoxical therapy case vignette:

Vignette one

Mary is a 46 year old female admitted with worsening depression, feeling overwhelmed at home due to marital discord, increase in joint pain. She lives in a house on 5 acres mostly by herself, her husband is a truck driver who is not home often and she feels not supported. She is an avid gardener and grows fruit and vegetables in her yard.

Vignette two

Tom is a 50 year old male with multiple medical problems, back pain, arthritis, obesity and depression. He has been more depressed lately, does not feel to get out of his home, and has lost interest. He lives in an apartment by himself after his divorce and wife moved out 6 months ago. His uncle lives on a farm and Tom always wanted to help his uncle in his garden but never really got a chance to do so. He does report that the apartment complex where he lives allows the tenants to garden in a designated gardening area wherein they can plant and grow up vegetable patch.

The thought of doing so has crossed his mind in the past but he did not know where to start.

Mary learns about it and teaches Tom all about growing tomatoes and avocados. Tom takes on this hobby and now after six months goes to village market every Saturday to sell his and Mary’s vegetables and fruits. They rent a stall together and help each other grow and sell and also make some money. They sell some, make some money but more importantly make more happiness than vegetables or money.

A number of strength-based strategies like well-being therapy, positive interventions, resilience-focused interventions, and resource-oriented approaches have been described [7-11]. The concept of Paradoxical therapy derives from these therapies and takes a more focused and positive approach of augmenting a clientâ€^™s positive skills/strengths. It also empowers patients by instilling a helper role. It is different from symptom prescription strategy used in paradoxical intention therapy that is used to treat conversion disorders [12].

This concept of Paradoxical therapy enhances patient strengths by empowering them and giving them mastery over their strengths. It enforces a role of help-provider besides help-seeker to improve self-esteem and coping. The paradigm consists of gradually increasing hierarchy of situations/scenarios that is patient centered and varies per the patient strengths. Patient strengths are used in real life situations, imagined scenarios or exposure to help improve coping skills.

Our limited case work describes as to how this concept of paradoxical therapy could be utilized for treatment, it has its limitations. Patients are in various stages and states of their psychopathology and well-being. The treatment paradigm needs to be tightly monitored to any added stress that it may impose on patients whose coping mechanisms may be already weak. Treatment using PT also needs to be tightly monitored and supervised by a trained professional.

Furthermore, Paradoxical psychotherapy needs to be studied in larger clinical trials and compared with treatment-as-usual.