BEHAVIOR THERAPY 9, 955-959 (1978)

Treatment of Insomnia by Paradoxical Intention:

A Time-Series Analysis
H E L M U T RELINGER, P H I L I P H. BORNSTEIN, AND D A N M . M U N G A S

University of Montana
Paradoxical instructions were presented to an individual suffering from chronic
insomnia. To control for improvement attributable to demand characteristics
alone, counterdemand manipulations were utilized during the treatment period.
Results, analyzed via time series analysis, indicated significant improvement on
five of eight self-recorded sleep dimensions. These findings were discussed with
regard to the hypothesized interruption of the "exacerbation cycle."

Paradoxical intention was first introduced into psychological literature

by Dunlap (1928) and later incorporated into a variety of psychotherapeu-
tic systems (Frankl, 1963; Gerz, 1966; Haley, 1973). The basic premise
underlying the technique has been, and continues to be, prescription of
the presenting complaint. That is, the therapist encourages and cajoles the
patient in the continuation and exacerbation of symptomatic behavior.
Unfortunately, all published claims of therapeutic success using the tech-
nique have thus far been based on either global, subjective forms of
evaluation or nonexperimental reports.
Interestingly, behavior therapists have now taken note of the paradoxi-
cal intention procedure and clinical programs aimed at demonstrating its
effectiveness have been initiated (Ascher, Note 1; Johnson & Alevizos,
Note 2). In a related area, Kazdin (1976) has recently recommended the
use of statistical tests for single-subject designs when conducting research
in " n e w " areas of behavioral intervention. The purpose of the present
investigation was therefore to empirically evaluate the effects of paradox-
ical intention utilizing time series analysis as the criteria for evaluation.
CASE STUDY
Subject
The subject was a 31-year-old housewife solicited for an insomnia
research project via a public service radio announcement. Pretreatment

Requests for reprints should be sent to Philip H. Bornstein, Department of Psychology,

University of Montana, Missoula, MT 59812

955
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Copyright© 1978by Associationfor Advancementof BehaviorTherapy.
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956 CASE REPORTS A N D S T U D I E S

questionnaire data revealed a noncyclical, chronic problem of 20-year

duration including repeated awakenings during the night as well as sleep
onset difficulties. While she had never sought professionial help for the
problem, a variety of over-the-counter drugs had been tried in the past
with little success. The subject was taking no medication at the time of the
study, nor was there any evidence of recent adjustment or situational
problems.
Dependent Measures
Data was recorded by the client on daily sleep charts, which required
her to assess the adequacy of rest on eight different sleep dimensions.
Specific items included: estimate of latency of sleep onset, total time
spent sleeping, number of awakenings during the night, number of times
experienced difficulty in falling back to sleep, and number of dreams
occurring. The final three items utilized five-point Likert scales to provide
information with regard to difficulty experienced in falling asleep, degree
of restfulness upon awakening, and estimate of personal functioning on
the previous day. Data was collected on a daily basis during a three-week
baseline, one-week treatment, and one-month followup period. In addi-
tion, for seven continuous days at 3-months and 12-months posttreat-
ment, sleep data was recorded by the subject and later forwarded to the
authors.
Procedure
Prior to the onset of treatment, the subject received a brief orientation
to the program and instructions in recording her daily sleep patterns.
Following this three-week baseline period, five daily half-hour treatment
sessions were initiated. The therapeutic strategy was to provide a believ-
able rationale for instructing the subject to attempt to remain awake as
long as possible. Thus, the subject was informed that she was to stay
awake so as to become aware of the exact thoughts and feelings she was
experiencing which were keeping her awake (Ascher, Note 1). She was
told that once these cognitions had been uncovered and recorded, they
would then be used in the development of a systematic desensitization
hierarchy. However, rather than pairing the items with relaxation, they
were, in fact, paired with neutral images. More specifically, the arousal
cognitions were paired with neutral images 10 times per session for 1-min
trials each. Furthermore, the subject was instructed to attempt to stay
awake at night to become aware of further disturbing cognitions, for as
long as she continued to experience sleep difficulties. If sleep disturbance
is viewed as a problem in which bedtime stimuli elicit responses (physio-
logical and/or cognitive) incompatible with sleep, then the imaginal pair-
ing of such stimuli with varied, neutral images should not theoretically
change that functional relationship (Steinmark & Borkovec, 1974). Thus,
 CASE REPORTS A N D S T U D I E S 957

while this quasi-desensitization procedure by itself produces no sig-

nificant improvement in sleep disturbance (Borkovec, Kaloupek, &
Slama, 1975; Steinmark & Borkovec, 1974), it did present the subject with
an ostensibly reasonable rationale for attempting to remain awake as
long as possible, and allow evaluation of the paradoxical intention proce-
dure without contamination by other active treatment components.
To control for improvement attributable to demand characteristics
alone, counterdemand instructions similar to those used by Steinmark and
Borkovec (1974) were presented to the subject throughout the five-day
treatment period. Thus, she was specifically told not to expect improve-
ment until the end of treatment. Any positive change reported during the
treatment period was, therefore, viewed as a demand-free conservative
estimate of "actual" improvement.

RESULTS
To test for the effects of treatment, time series analysis (Box & Jenkins,
1970; Glass, Willson, & Gottman, 1975) was performed on each of the
dependent variables. This consisted of a two-step process: (a) identifica-
tion of the appropriate model to account for serial dependency in the time
series, and (b) testing for the effects of treatment using normal theory
least squares analysis of scores, transformed according to the identified
model so as to eliminate serial dependency. An ARIMA (1, 0, 0) model
was identified for the latency of sleep onset variable, while the model for
all seven other dependent variables was identified as an ARIMA (0, 0, 0),
indicating a lack of serial dependency.
Least squares analysis t-tests were then performed to test for change in
level associated with the counterdemand treatment and followup period.
Results indicated significant decreases in level during treatment for: "la-
tency of sleep onset," "number of times experienced difficulty falling
back to sleep," "difficulty in falling asleep," "degree of restfulness upon
awakening," and "estimate of personal functioning on the previous day."
Although no change was found during the treatment period, "number of
times awakened during the night" did significantly improve during the
one-month followup period. Table 1 indicates, for each dependent vari-
able, baseline, treatment, and followup level of the series.
For those variables on which a significant decrease in level following
the onset of treatment was found, a further analysis was performed in
order to test for drift back to pretreatment level during the one-month
followup period. This was accomplished by performing least squares
analysis utilizing appropriate parameters in the model to account for
deterministic drift during the followup period. Results indicated none of
the t-values used to test those parameters approached significance (p >
.20).
958 CASE R E P O R T S A N D S T U D I E S

TABLE i
AVERAGE LEVEL OF DEPENDENT VARIABLES DURING BASELINE, TREATMENT, AND
FOLLOWUP PERIODS

Variable Baseline Treatment a l-mo. F U b 3-mo. F U 12-mo. F U

L a t e n c y of sleep o n s e t 64.37 15.07" 20.17 6.57 10.71

Total time sleeping 5.67 5.57 5.81 6.71 6.43
N u m b e r of awakenings 2.52 2.85 1.25" .29 0.71
Difficulty falling 1.38 .57* .29 0 0.14
back to sleep
N u m b e r of d r e a m s 1.57 2.14 2.11 1.86 1.43
Difficulty falling 3.48 1.58"* 1.42 1.00 1.00
to sleep
Restfulness upon 3.14 1.43** 1.30 1.00 1.00
awakening
Personal functioning 3.00 1.57* !. 15 1.00 1.00
previous day

Note. Time series analysis was not performed on either 3-too. foliowup or 12-too.
followup data d u e to unequal intervals b e t w e e n observational periods. In s u c h cases,
p a r a m e t e r estimation m a y be biased, thereby rendering statistical tests inappropriate.
a p values refer to change in level as a result of treatment.
b p values refer to change in level from treatment to l-mo. followup.
* p < .01
** p < .001

DISCUSSION
The results of the present single-subject investigation indicate clear
improvement of insomnia-related behaviors through the utilization of the
paradoxical intention procedure. Of the eight dependent measures, five
evidenced significant improvement during the treatment phase with sub-
stantial gains maintained over the 12-month followup period. The fact that
these reductions in symptoms occurred during the counterdemand condi-
tion further allows for the separation of valid treatment effects from
therapeutic expectancy and demand characteristics. Moreover, this re-
port represents the first successful attempt to reliably assess the efficacy
of paradoxical techniques via time series methods.
The current findings demonstrate that instructing an individual who has
been suffering from sleep difficulties for over 20 years, to "remain awake
as long as you can after going to bed at night" can, in fact, relieve
self-rated sleep disturbance. While many explanations for this phenome-
non seem feasible, the most parsimonious rationale involves interruption
of the "exacerbation cycle" (Ribordy & Denney, 1977). That is, sleep
difficulties reported by chronic insomniacs may be compounded and
consequently caused by worries about not succeeding in attempts to fall
asleep. Thus, a vicious cycle results in which the insomniac's solution to
the problem (i.e., attempting to fall asleep) becomes an internal anxiety-
 CASE REPORTS AND STUDIES 959

eliciting stimulus which only serves to exacerbate his/her autonomic

arousal and thereby further reduce his/her ability to fall asleep. The
instructions to "remain awake" then, allow for interruption of this cycle
by eliminating the hypothesized anxiety-arousing stimulus.
It would appear that paradoxical instructions are an effective treatment
modality for the alleviation of chronic insomnia. Whether the rationale
presented above adequately describes the actual ameliorative process
remains a moot question. Future researchers should therefore attempt to
obtain presleep autonomic arousal measures as well as objective changes
in sleep patterns as a means of assessing active therapeutic agents within
the paradoxical procedure. Future investigations should also be directed
toward assessing the efficacy of the paradoxical intention procedure
across individuals manifesting different types of insomnia symptoms, in
an attempt to delineate scope and limitations of the procedure.
REFERENCES
Borkovec, T. D., Kaloupek, D. G., & Slama, K. M. The facilitative effect of muscle tension
release in the relaxation treatment of sleep disturbance. Behavior Therapy, 1975, 6,
301-309.
Box, G. E. P., & Jenkins, G. M. Time series analysis: Forecasting and control. San
Francisco: Holden-Day, 1970.
Dunlap, K. A revision of the fundamental law of habit formation. Science, 1928, 67,
320-322.
Frankl, V. E. Man's search for meaning: An introduction to logotherapy. New York:
Washington Square Press, 1963.
Gerz, H. O. Experience with the Iogotherapeutic technique of paradoxical intention in the
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Psychiatry, 1966, 123, 548-553.
Glass, G. V., Willson, V. L., & Gottman, J. M. Design and analysis of time-series experi-
ments. Boulder: Colorado Associated University Press, 1975.
Haley, J. Uncommon therapy. New York: Ballantine Books, 1973.
Kazdin, A. E. Statistical analyses for single-case experimental designs. In M. Hersen and D.
Barlow (Eds.), Single case experimental designs: Strategies for studying behavior
change. New York: Pergamon, 1976.
Ribordy, S. D., & Denney, D. R. The behavioral treatment of insomnia: An alternative to
drug therapy. Behaviour Research and Therapy, 1977, 15, 39-50.
Steinmark, S. W., & Borkovec, T. D. Active and placebo treatment effects on moderate
insomnia under counterdemand and positive demand instructions. Journal of Abnormal
Psychology, 1974, 83, 157-163.

REFERENCE NOTES
1. Ascher, L. M. Paradoxical techniques in behavior therapy: Single case studies in the
treatment of insomnia. Paper presented at the meeting of the Association for the Ad-
vancement of Behavior Therapy, San Francisco, December 1975.
2. Johnson, S. M., & Alevizos, P. N. Strategic therapy: A systematic outline of procedures.
Paper presented at the meeting o f the Association for the Advancement of Behavior
Therapy, San Francisco, December 1975.

RECEIVED: April 4, 1977; FINAL ACCEPTANCE: October 20, 1977