by Allan Barsky, J.D., MSW, Ph.D.
Paradox
Respect for the dignity and worth of all people is a core social work value. The NASW Code of Ethics implements this value through a number of ethical obligations, including the duty to ensure clients are properly informed about the interventions they are being offered (Standard 1.03). Providing accurate information about interventions gives clients the ability to accept or reject services based on a thorough understanding of the nature of services, including their risks and benefits. Social workers are also prohibited from participating in fraud or deception (Standard 4.04), meaning that social workers should be honest and provide clients with full disclosure about their services.
For many social work interventions, being honest with clients and providing truthful information about services does not pose significant ethical challenges. For some interventions, however, deception (or at least lack of full disclosure) is vital to the effectiveness of the intervention. In this article, we explore the ethics of one such type of intervention—paradoxical intervention.
When social workers or other mental health professionals use paradoxical interventions, they encourage clients to behave in a particular way, expecting the clients to behave in a different manner. Consider, for instance, a child who has been lighting fires, posing danger to people and property. A social worker might ask the child to light a fire during a therapy session. Because the child is now receiving permission to light the fire, the child might choose not to do so. Alternatively, the child might light the fire and the worker could use the opportunity to teach the child about lighting fires in a safer manner. If the social worker explains the purpose of the intervention in advance, it will not work.
Social workers may also use paradoxical interventions with families to help them extinguish problematic patterns of behavior. Consider a family that has been arguing. The social worker could say, “I would like to see how you argue. Watching you argue would be very helpful.” The clients may either accept or reject these instructions; however, they do not know that the worker is using a paradoxical intervention. Although the worker seems to be encouraging further arguments, the purpose of the intervention is to discourage them from arguing. By asking them to continue arguing, the family members may become aware of the absurdity of their behavior and decide to stop arguing.
Social workers are supposed to provide clients with full and honest information to enable them to exercise informed consent. Still, remember that most standards in the NASW Code of Ethics are not absolute rules. The language for these standards says social workers “should” provide valid informed consent and “should not” participate in deception. This language suggests that there may be exceptions, provided there are sufficient ethical justifications to supersede these general obligations. From a consequentialist (teleological) perspective, one argument is that the end justifies the means. In other words, if workers can demonstrate that paradoxical interventions are effective, they can argue that withholding information from clients is justifiable. Although there are risks, the benefits of the intervention outweigh the risks. If paradoxical interventions are not effective—or perhaps are too risky—then using them is not ethically justifiable.
As with many ethical issues, we should be careful about asking simple yes/no questions. Rather than asking, “Are paradoxical interventions ethical?” we might be better served by asking, “Under what circumstances, if any, are paradoxical interventions ethically justifiable?” This question allows us to consider more nuanced answers.
In the example of asking a child to light fires, for instance, the worker might not be able to explain the purpose of the paradoxical intervention to the child. However, the worker might be able to obtain informed consent from the parents, after explaining the purpose, risks, and benefits to them. The worker might also explain how the risks will be managed. If the worker plans to suggest that the child light a fire at school, for instance, the intervention would be riskier and, therefore, not justifiable. In the original example, the worker asks the child to light the fire during the therapy session, giving the worker the opportunity to monitor and intervene to ensure the child and others are safe. The worker might also provide the parents with guidelines to ensure the child continues to be safe after leaving the office.
Certain types of paradoxical interventions may simply be too risky or ill conceived. Consider, for instance, a client in acute crisis. Instructing her to take a cyanide pill to die by suicide would be an example of paradoxical intervention; however, this intervention would clearly be inappropriate, as the risk of harm is too great and the client might think you are making fun of her situation.
Some social workers might try to justify the use of paradoxical interventions by suggesting, “Although the client is not giving prior consent to the intervention, she or he will be thankful for the intervention after the fact.” Consider a client with alcohol dependence. The worker could argue that the client’s brain has been hijacked by the alcohol and the client cannot make good rational decisions at this time. This approach is paternalistic, suggesting that the worker knows better than the client about what is good for the client. The social worker might be able to use a paradoxical intervention and still respect the client’s rights to self-determination and informed consent. If the client is saying, “I don’t have a problem. I can stop drinking whenever I want,” the worker can suggest that the client continue to drink, and also, monitor his drinking, to show the worker that there is no problem. Thus, the worker is encouraging the client to do what the client is already planning to do. The worker does not want the client to continue, but—arguably—the worker is not deceiving the client.
By encouraging the client to monitor drinking, the ability to stop drinking, and the consequences of drinking, however, the worker may help the client realize that he does not have control and drinking is causing problems. Initially, the client may feel relieved that the worker is not expecting him to abstain from drinking. The worker is also building trust with the client by allowing him to determine whether drinking is problematic.
Although one could argue that the worker is not fully disclosing the purpose of the intervention, the worker is not engaging in a blatant form of deception. Thus, when assessing for honesty and full disclosure, workers may consider levels of honesty and full disclosure.
In contrast to a consequentialist perspective, deontology focuses on the ethical obligations or acts rather than the consequences of the acts. According to deontologists, social workers should be honest—positive consequences do not justify deception. Social workers can draw from many different models of intervention and change strategies. Why not choose strategies that do not employ deception or lack of full disclosure? Even from a consequentialist perspective, social workers should be asking whether deception is necessary. Paradoxical interventions may be risky—and this includes not just the risks that the clients will continue or intensify the behaviors that the worker is trying to extinguish. When workers employ paradoxical interventions, clients may discover the deceptive element of the intervention and lose trust in the worker—and perhaps, lose trust in all social workers.
Some social workers may decide that the risks of paradoxical interventions are too great and, therefore, paradoxical interventions are not warranted. Others may decide that some types of paradoxical interventions are ethically justified in certain circumstances. Note that the standard of care for malpractice lawsuits considers what a prudent social worker, acting reasonably, might do in a similar situation. Accordingly, when considering whether a particular paradoxical intervention is ethical, social workers would be wise to consult with other social workers to determine whether they believe that the intervention would be reasonable.
As a matter of risk management, social workers could also document how they arrived at their decision to use the paradoxical intervention. What was the purpose of the intervention? What are the benefits and risks of the intervention? What other interventions were considered? What were the views of people they consulted, and what factors led to the decision to use the particular intervention?
To the lay person, paradoxical interventions (sometimes called “reverse psychology”) may sound cool or fascinating. For social workers, the decision to use a paradoxical intervention needs to be taken with due consideration of ethical concerns related to informed consent, honesty, potential benefits, and risks.
Allan Barsky, Ph.D., J.D., MSW, is Professor of Social Work at Florida Atlantic University and author of Social Work Values and Ethics (Oxford University Press).
The views expressed in this article do not necessarily represent the views of any of the organizations to which the author is affiliated, or the views of The New Social Worker magazine or White Hat Communications.