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Paradoxical intention and insomnia: An experimental investigation
Abstract
A study by Turner and Ascher (1978) compared the efficacy of progressive relaxation, stimulus control, and paradoxical intention in ameliorating sleep onset insomnia. Results indicated that the three were equally effective. The present study is a partial replication of Turner and Ascher (1978) and focuses on the use of paradoxical intention in reducing sleep difficulties.Twenty-five individuals complaining of sleep discomfort were randomly assigned to three groups: paradoxical intention, placebo control, no treatment control. Clients in the paradoxical intention group were instructed to remain awake while lying in bed in a darkened room. The complete rationale for such a prescription was provided. Those in the placebo group received a pseudo systematic desensitization program.Results indicated that subjects exposed to the paradoxical intention procedure reported significant improvement on several measures of sleep behavior when compared with reports of subjects in either placebo or no-treatment control groups.
... Paradoxical techniques in psychotherapy have been described for a long time. The use of Paradoxical Intention for insomnia was adapted from Viktor Frankl's work [10] by Michael Ascher and others in the late 1970s [11,12] when it was observed that people with insomnia had more success falling asleep when they tried to remain awake than they had when they tried to fall asleep. There is no evidence to suggest that PIT is differentially effective in sleep onset and sleep maintenance in insomnia [13]. ...
... A five-point Likert scale is used to rate each item (e.g., 0 = no problem; 4 = very severe problem), yielding a total score ranging from 0 to 28. The total score is interpreted as follows: the absence of insomnia (0-7); sub-threshold insomnia (8)(9)(10)(11)(12)(13)(14); moderate insomnia (15)(16)(17)(18)(19)(20)(21); and severe insomnia (22)(23)(24)(25)(26)(27)(28). ISI is a reliable and valid instrument to quantify perceived insomnia severity [8,15]. ...
... Intention is considered to work by reducing performance anxiety (the poor sleeper's inability to produce the criterion performance for good sleep) and by reducing associated sleep worry and sleep preoccupation [26]. Ascher and Turner (1979) compared the efficacy of progressive relaxation, stimulus control, and paradoxical intention in ameliorating sleep-onset insomnia. Results of their study indicated that the three were equally effective ( Table 3). ...
Introduction: Insomnia is the most prevalent of all sleep disorders. Non-pharmacological interventions in recent years have
been established as first-line treatment for nonorganic insomnia. Studies have shown Cognitive Behavior Therapy for Insomnia
(CBT-I) to be effective for primary insomnia. Paradoxical intention is a Logo-therapeutic technique based on the existential
origins of the founder, Viktor E. Frankl. Past researches into the effectiveness of paradoxical Intention interventions have been
inconsistent. There is a lack of evidence that Paradoxical Intention Therapy is differentially effective in insomnia when compared
with CBT-I.
Aim: To evaluate and compare the effectiveness of CBT-I and PIT and to study their effects on mental health in Non-Organic
Insomnia in young adults.
Method: Participants: A mixed-gender group of 20 young adults with a mean age of 25.35 years.
Procedure: Participants were recruited via an online survey with the help of the Insomnia Severity Index. 100 participants
responded to the online survey on Insomnia Severity Index out of which 24 met the inclusion criteria and finally 20 participants
gave their consent to undergo the intervention modules. Participants were randomly assigned to two intervention groups namely
CBT-I (n=10) and PIT group (n=10). Both the interventions were given for two months. Scores of Insomnia Severity Index,
Pittsburg Sleep Quality Index, and Mental Health Inventory were taken as outcome measures at baseline (Pre-Intervention), at
the end of the intervention (Post Intervention), and in a follow-up assessment after 45 days, assessment of Insomnia Severity
and Sleep Quality was done to study the maintenance of the therapeutic effect and relapse. An informed consent was taken from
participants before the intervention results: It was found that both CBT-I and PIT are effective. Although CBT-I was associated
with greater improvements than PIT. Both the groups showed significant improvements in the scores of outcome measures. The
overall patterns of change with treatment demonstrated statistically and clinically significant improvements in the severity of
insomnia symptoms as well as statistically significant differences in sleep quality and mental health.
Conclusion: Both CBT and PIT are effective in non-organic insomnia but CBT-I might be a substantial treatment of choice with a
more sustained and high effect for CBT-I when compared to Paradoxical Intention Therapy.
... Nineteen RCTs compared a cognitive component or therapy with a more passive comparator, i.e., psychoeducation, monitoring, no treatment or a waitlist control [31e49]. Four RCTs used a psychological placebo as a comparator [33,34,36,47,50]. One RCT compared a cognitive program with biofeedback [51]. ...
... First, we present studies that have investigated the most common form of paradoxical intention administration (type A) [33]. The type A rationale is based on that sleep-related performance anxiety is likely to result in sleep difficulties, mainly sleep-onset insomnia. ...
... In the type A administration, the patient is instructed to remain awake for as long as possible under sleep-compatible conditions natural for the onset and maintenance of sleep (e.g., lights out) and not to move around or engage in behavior specifically designed to prevent sleep. In one early study [33], paradoxical intention, placebo and a no-treatment condition were compared. The findings demonstrated that paradoxical intention was superior to the other two groups on sleep onset latency, number of awakenings, and difficulty falling asleep at post-treatment. ...
Since the beginning of the twenty-first century, there has been an increased focus on developing and testing cognitive components and therapies for insomnia disorder. The aim of the current review was thus to describe and review the efficacy of cognitive components and therapies for insomnia. A systematic review was conducted on 32 studies (N=1455 subjects) identified through database searches. Criteria for inclusion required that each study constituted a report of outcome from a cognitive component or therapy, that the study had a group protocol, adult participants with diagnosed insomnia or undiagnosed insomnia symptoms or reported poor sleep, and that the study was published until and including 2016 in English. Each study was systematically reviewed with a standard coding sheet. Several cognitive components, a multi-component cognitive program, and cognitive therapy were identified. It is concluded that there is support for paradoxical intention and cognitive therapy. There are also other cognitive interventions that appears promising, such as cognitive refocusing and behavioral experiments. For most interventions, the study quality was rated as low to moderate. We conclude that several cognitive treatment components and therapies can be viewed as efficacious or promising interventions for patients with insomnia disorder. Methodologically stronger studies are, however, warranted.
... Another type of rationale, which was delivered to the remaining 2 patients in the study by Ascher and Efran, 1 was to instruct patients to resist the urge to sleep and to apply relaxation in bed to reach a satisfactory level of relaxation and subsequently to be able to fall asleep. A third type of PI was also described in an article by Ascher and Turner,2 in which patients were instructed to apply PI while keeping their eyes open and lying comfortably in bed or in a dark room (also known as Type A instructions). Based on how PI is used in later studies, we draw the conclusion that the last rationale by Ascher and Turner 2 seems to be the one that nowadays is regarded as "true" PI, for example, described by Espie 3 ; this also means that the first 2 types, which involve observing thoughts or applying relaxation, seem outdated in the treatment literature. ...
... In a few studies, patients were cautioned not to expect improved sleep until after a few weeks of treatment. 2,5 This caveat might be wise because one study reported that a third of the participants experienced longer sleep onset latencies during the first week of PI, although sleep onset had shortened by the end of treatment. 28 This report corresponds with our clinical experience, wherein some report prolonged sleep onset after PI. (Regrettably, we do not know how their trajectories would have played out because our patients were instructed to try another technique instead, during comprehensive CBT-I with new techniques being introduced most weeks). ...
Paradoxic intention (PI) was one of the first psychological interventions for insomnia. Historically, PI has been incorporated in cognitive behavioral therapy for insomnia (CBT-I) or delivered as a sole intervention for insomnia. PI instructions have varied over the years, but a common denominator is the instruction to try to stay awake in bed for as long as possible. This article reviews and discuss treatment rationales and theoretic frameworks for PI, the current evidence base for PI, its clinical relevance, and considerations needed when PI is used as an adjunct treatment to CBT-I, or as a second-line intervention for insomnia.
... Results indicated longer sleep onset times for those asked to sleep as quickly as possible. Also in clinical settings, paradoxical intention therapy is used, aiming at taking the pressure of falling asleep from subjects by telling them to stay awake (Ascher & Turner, 1979;Espie, 1987;Ladouceur & Gros-Louis, 1986;Morin et al., 1999). Thus, to influence sleep, cognitive approaches might not be easily implemented successfully and consciousness is possibly even better circumvented. ...
... Thus, changing inappropriate beliefs concerning sleep is one major target in clinical approaches to treat sleep disturbances (Morin, Blais, & Savard, 2002). However, intentionally "wanting" to fall asleep is often counterproductive; therefore, paradoxical interventions are sometimes more helpful to induce sleep (Ascher & Efran, 1978;Ascher & Turner, 1979). Thus, inducing sleep or extending SWS under hypnosis might bypass the explicit and voluntary intention, inducing subsequent sleep effects on a more subconscious level, not involving willing decision processes. ...
... After the first promising study in 1978, other trials in following years also investigated the efficacy of PI with similar results. [6][7][8] In later years, PI has been reviewed favourably. 9 Previously, two theoretical models of PI have been presented to account for why PI results in positive effects for patients with insomnia disorder. ...
Introduction Paradoxical intention (PI) is an insomnia treatment developed in the 1970s, which instructs patients to gently attempt to remain awake while in bed at night with the lights off. Previous research indicates PI’s potential in improving insomnia, although no study has been conducted in the last few decades during which the insomnia diagnostic criteria have changed. Additionally, there are knowledge gaps regarding outcomes related to wake after sleep onset, the treatment mechanisms as well as the acceptability and feasibility of the treatment. This study therefore aims to address these gaps by assessing the potential mechanisms, preliminary efficacy, and patient experience and acceptability of PI.
Methods and analysis We aim to include 40 adult participants with insomnia, aged 18 and above, from the Swedish general population. In this uncontrolled pilot study using a mixed-methods approach, both qualitative and quantitative data will be collected. The trial will be conducted on a self-help online platform, accessible from participants’ homes, with weekly phone call support by therapists. Process and outcome measures will be assessed weekly across a 4-week intervention period and at a 3-month follow-up. A subset of participants will be asked to participate in qualitative semistructured interviews regarding the treatment.
Ethics and dissemination Ethical approval for this project has been granted by the Swedish Ethical Review Authority (Dnr: 2023-06594-01). All participants will sign informed consent forms on a web service application prior to enrolment. From this mixed-methods study, we anticipate insights into the preliminary efficacy and mechanisms of paradoxical intention for treating insomnia, enriched by patient experience data. Results will be disseminated through peer-reviewed publications. The findings will inform adaptations to the treatment protocol and serve as groundwork for a possible larger scale randomised controlled trial.
Trial registration number NCT06259682.
... It is thought that while the patient's performance anxiety becomes focused on doing the opposite, falling asleep becomes an easier task to achieve and can come spontaneously. Different studies has shown the effectiveness of this method in treating insomnia (Ascher & Turner, 1979;Ladouceur & Gros-Louis, 1986). ...
... Therapist type, training, and supervision Treatment integrity check Ascher and Turner (1979) (1) Attempt to remain awake as long as possible rather than continuing the effort to fall asleep, (2003) (1) At lights out: stay awake for as long as possible by keeping eyes open, (2) resist sleep-onset gently but persistently in an environment conducive to sleep, and (3) not engage in active methods to stay awake. the notion that decreased performance anxiety is a mechanism through which PI might work. ...
Paradoxical intention (PI) has been considered an evidence‐based treatment for insomnia since the 1990s, but it has not been evaluated with modern review techniques such as meta‐analysis. The present study aimed to conduct the first systematic review and meta‐analysis of studies that explore the effectiveness of PI for insomnia on insomnia symptomatology and theory‐derived processes. A systematic review and meta‐analysis was conducted by searching for eligible articles or dissertations in six online bibliographic databases. Randomised controlled trials and experimental studies comparing PI for insomnia to active and passive comparators and assessing insomnia symptoms as outcomes were included. A random effects model was estimated to determine the standardised mean difference Hedge’s g at post‐treatment. Test for heterogeneity was performed, fail‐safe N was calculated, and study quality was assessed. The study was pre‐registered at International Prospective Register of Systematic Reviews (PROSPERO, CRD42019137357). A total of 10 trials were identified. Compared to passive comparators, PI led to large improvements in key insomnia symptoms. Relative to active comparators, the improvements were smaller, but still moderate for several central outcomes. Compared to passive comparators, PI resulted in great reductions in sleep‐related performance anxiety, one of several proposed mechanisms of change for PI. PI for insomnia resulted in marked clinical improvements, large relative to passive comparators and moderate compared to active comparators. However, methodologically stronger studies are needed before more firm conclusions can be drawn.
... Paradoxical intention essentially requires participants to get into bed and purposefully stay awake. In other words, this module prescribes the symptom as part of the solution; something that has been shown to improve sleep quality (Ascher & Turner, 1979;DeBord, 1989;Perlis et al., 2010). The rationale behind paradoxical intention assumes that problems falling asleep are, in part, maintained by anxieties around the act of falling asleep itself. ...
Background: Sleep and mental health go hand-in-hand, with problems sleeping being associated with a variety of mental health difficulties. Recently, insomnia has been linked with the experience of paranoia, a relationship that is likely to be mediated by negative affect. Given these links, the present research aimed to test whether a self-help intervention designed to improve sleep can also improve negative affect and paranoia.
Method: Participants were recruited from a mailing list of University staff and were randomly allocated to one of three conditions; a wait-list control group, an active control group who completed a sleep diary each day for 6 weeks, and an experimental group who received an online self-help intervention targeting sleep problems alongside the same sleep diary. Levels of insomnia, negative affect, and paranoia were measured at baseline, immediately post-intervention, and 4- and 18-weeks post-intervention.
Results: There were no significant differences between the groups on levels of insomnia, negative affect, and/or paranoid thinking at post-intervention, 4-weeks, or the 18-week follow-up. However, a relatively large number of participants dropped out of the study, particularly in the intervention group, which meant that the primary analysis was underpowered.
Conclusion: Due to a high level of participant dropout, the findings from the present research are inconclusive, and suggest that retaining participants in trials of online interventions is a significant challenge that needs to be addressed in future research.
... En esta línea, las investigaciones subsecuentes se enfocaron a disminuir los componentes fisiológicos de los pacientes con insomnio, analizando la eficacia de la relajación a través de auto reportes de estudio de caso (Weil y Goldfried, 1973), retroalimentación biológica (Biofeedback) (Borkovec y Weerts, 1976;Borkovec et al., 1979) técnicas de relajación muscular en combinación con drogas sedantes (Borkovec y Fowles, 1973) o con otras técnicas terapéuticas como la intención paradójica (Nicassio y Bootzin, 1974;Geer y Katkin, 1966;Ascher y Turner, 1979). ...
Los trastornos de sueño son una problemática recurrente en la actualidad. A pesar de los múltiples estudios sobre intervenciones eficaces, es poca su difusión en la literatura hispanohablante. A partir de esta necesidad, el objetivo del presente artículo es dar a conocer las intervenciones con mayor efectividad sobre los trastornos del sueño, como son el Insomnio, Síndrome de Apnea-Hipopnea Obstructiva de Sueño (SAHOS) y Narcolepsia. Se revisó: características del sueño, criterios diagnósticos con base en la clasificación internacional de trastornos de sueño y las intervenciones psicológicas para cada uno los trastornos antes mencionados.
... Ascher and Turner [102] found that PI-A produced a greater reduction in subjective SOL compared with PI-B, an active placebo control group (i.e., quasi-desensitization), and a passive control group. Ascher and Turner [103] also found a superior effect of PI-A on subjective SOL compared with a placebo control group (i.e., quasi-desensitization) and a passive control group. Similarly, in a third study [104], individuals who received PI-A improved more on subjective SOL than individuals in a passive control group, and this effect was still apparent after 3, 6, and 17 months. ...
... Addressing the "racing mind": learning how to cope or deal with worries and thought that prevent the person from falling asleep Paradoxical intention: trying to stay awake instead of falling asleep [12] Additive Relaxation: relaxation and breathing techniques to teach persons to unwind [13] Mindfulness: using techniques from mindfulness to teach persons to unwind [14] Lichstein et al. [20] Kuhn et al. [21] Therapist-guided dCBT Automated dCBT with guidance and tailoring supported by human therapists Partly Lancee et al. [22] Van Straten et al. [23] Blom et al. [24] Fully automated dCBT Fully automated and tailored dCBT without in-person clinical support Fully Ritterband et al. [25] Vincent et al. [26] Espie et al. [27] the program is offered without any human support. Personalization is built into the automated program using algorithms to tailor all aspects of the program, including personalized feedback and a tailored treatment program. ...
Purpose of Review
Digital cognitive behavioral therapy (dCBT) has been available for over a decade. We reviewed the evidence that accumulated over the past 5 years and discuss the implications for introducing dCBT into standard healthcare.
Recent Findings
Studies have consistently supported the use of dCBT to treat insomnia. Evidence is now demonstrating large short-term effects and smaller long-term effects up to 1.5 years after treatment across populations with various co-occurring health problems. The effects also extend into a range of psychological well-being factors. Mediators and moderators have been studied to understand mechanisms and create new opportunities to enhance effectiveness and reduce dropout. Incorporating personalized guidance in dCBT may further enhance effectiveness.
Summary
The evidence for dCBT for insomnia is strong and suggests that dCBT is ready for application in standard healthcare. Further research, digital innovation, and development of effective implementation methods are required to ensure dCBT fulfills its potential.
... [18] Paradoxical intention procedure is effective on several measures of sleep behavior as compared to either placebo or no treatment. [42] Pharmacological interventions Drug therapy can be effective for short-term alleviation of insomnia but may not be sufficient for long-term management of chronic insomnia [ Table 1]. Behavioral therapy, on the other hand, yields the most durable improvements in sleep patterns. ...
Chronic insomnia is a fairly common condition affecting one-fourth of the clinical population. It has been variously defined and is related to a large number of conditions. A thorough assessment of the patient presenting with chronic insomnia is of vital importance for the treatment. Treatment consists of modifying sleep habits to reduce autonomic and cognitive factors and education about healthier sleep practice. Drug treatment should be reserved for the short-term alleviation of insomnia. Appropriate treatment of chronic insomnia improves the quality of life. The prevention of insomnia consists of a balance of rest, recreational exercise in combination with stress management and a healthy diet.
... Paradoxical intention has been evaluated in six studies meeting inclusion criteria. 38,47,49,54,55,77 All six studies focused on the problem of sleep-onset insomnia. In four studies, 38,49,54,77 paradoxical intention was more effective than control conditions in reducing sleep onset latency, whereas two studies 47,55 failed to report significant differences between this treatment and a placebo or wait-list control condition at posttreatment. ...
This paper reviews the evidence regarding the efficacy of nonpharmacological treatments for primary chronic insomnia. It is based on a review of 48 clinical trials and two meta-analyses conducted by a task force appointed by the American Academy of Sleep Medicine to develop practice parameters on non-drug therapies for the clinical management of insomnia. The findings indicate that nonpharmacological therapies produce reliable and durable changes in several sleep parameters of chronic insomnia sufferers. The data indicate that between 70% and 80% of patients treated with nonpharmacological interventions benefit from treatment. For the typical patient with persistent primary insomnia, treatment is likely to reduce the main target symptoms of sleep onset latency and/or wake time after sleep onset below or near the 30-min criterion initially used to define insomnia severity. Sleep duration is also increased by a modest 30 minutes and sleep quality and patient's satisfaction with sleep patterns are significantly enhanced. Sleep improvements achieved with these behavioral interventions are sustained for at least 6 months after treatment completion. However, there is no clear evidence that improved sleep leads to meaningful changes in daytime well-being or performance. Three treatments meet the American Psychological Association (APA) criteria for empirically-supported psychological treatments for insomnia: Stimulus control, progressive muscle relaxation, and paradoxical intention; and three additional treatments meet APA criteria for probably efficacious treatments: Sleep restriction, biofeedback, and multifaceted cognitive-behavior therapy. Additional outcome research is needed to examine the effectiveness of treatment when it is implemented in clinical settings (primary care, family practice), by non-sleep specialists, and with insomnia patients presenting medical or psychiatric comorbidity.
... Ascher and Turner [102] found that PI-A produced a greater reduction in subjective SOL compared with PI-B, an active placebo control group (i.e., quasi-desensitization), and a passive control group. Ascher and Turner [103] also found a superior effect of PI-A on subjective SOL compared with a placebo control group (i.e., quasi-desensitization) and a passive control group. Similarly, in a third study [104], individuals who received PI-A improved more on subjective SOL than individuals in a passive control group, and this effect was still apparent after 3, 6, and 17 months. ...
The purpose of the research programme detailed in this paper is to update the attachment control system framework that John Bowlby set out in his formulation of Attachment Theory. It does this by reconceptualising it as a cognitive architecture that can operate within multi-agent simulations. This is relevant to computational psychiatry because attachment phenomena are broad in scope and range from healthy everyday interactions to psychopathology. The process of attachment modelling involves three stages and this paper makes contributions in each of these stages. Firstly, a survey of attachment research is presented which focuses on two important attachment behavioural measures: the Strange Situation Procedure and the Adult Attachment Interview (AAI). These studies are reviewed to draw out key behavioural patterns and dependencies. Secondly, the empirical observations that are to be explained in this research programme are abstracted into scenarios which capture key behavioural elements. The value of behavioural scenarios is that they can guide the simulation design process and help evaluate simulations which are produced. Thirdly, whilst the implementation of these scenarios is still a work in progress, several designs are described that have been created and implemented as simulations. These include normative and non-pathological infant behaviour patterns observed across the first year of life in naturalistic observations and ‘Strange Situation’ studies. Future work is described which includes simulating dysfunctional infant behaviour patterns and a range of adult attachment behaviour patterns observed in the Adult Attachment Interview. In conclusion, this modelling approach is distinguished from other approaches in computational psychiatry because of the psychologically high level at which it models phenomena of interest.
... The first wave of psychotherapy for insomnia included single-component treatments that took a strictly behavioral focus. These treatments, which ranged from paradoxical intention [30][31][32] to stimulus control [33] to sleep restriction [34] among others, were administered as stand-alone interventions in clinical trials and were the first to gather empirical support as non-pharmacological treatments for insomnia. As the field of psychotherapy moved towards a focus on patterns of thinking during the second wave, insomnia treatments followed, with cognitive therapy for insomnia [35] emerging as a treatment specifically targeting the maladaptive beliefs about sleep and cognitive arousal commonly associated with the disorder. ...
The development of psychological and behavioral therapies over the past several decades has led to what is termed the third wave of psychotherapy, a collection of treatments that adopt a new approach to maladaptive cognitions and target broad, contextualistic goals. Within the field of behavioral sleep medicine, treatments for insomnia have followed a similar evolution, and several emerging therapies, including mindfulness and acceptance-based therapies, have begun to accumulate evidence as effective treatments for this sleep disorder over the past several decades. This paper discusses the historical background of the third wave of psychotherapy, introduces each of the third-wave therapies that have been applied to the treatment of insomnia, and reviews the recent literature to critique the effectiveness of these treatments. Relevant controversies with the third-wave therapies are discussed to inform future directions in insomnia research.
... Após três semanas de intervenção foi observada uma significativa redução na latência do sono (de 62 para 29 minutos), tendo os autores concluído que esse método era efetivo para facilitar o início do sono. 18 Um outro estudo avaliou a eficiência da terapia de controle dos estímulos para o tratamento da insônia crônica. Os resultados demonstraram uma redução significativa no tempo acordado após o início do sono o que sugere que a terapia de controle dos estímulos é um bom método para consolidar o sono dos pacientes. ...
The purpose of this manuscript is to briefly describe the main modalities of non-pharmacological therapy and its utilization on the chronic insomnia treatment. Insomnia is the most frequent sleep disorder and that is more associated with psychiatry disorders. The pharmacotherapy is the most frequent treatment, but the nonpharmacologic therapy has been studied. The most common therapy modalities include behavioral approaches, stimulus control, sleep restriction, paradoxical intention, sleep hygiene, progressive muscle relaxation and biofeedback and, more recently, physical exercise practices. At first behavioral therapy aimed to improve sleep quality, however, recent studies have been emphasizing the effect of behavioral and cognitive approaches on quality of life, on decrease of dosage and frequency of drugs intake. Since insomnia is a chronic condition, long-term and safe treatments are warranted.
... Encouraging insomniacs to stay awake can help them to sleep (Ascher & Efran, 1978;Turner & Ascher, 1979). This paradoxical effect may occur because the recommendation to stay awake discontinues the person's attempt to try to sleep and thus cuts short the ironic monitor that promotes wakefulness. ...
A theory of ironic processes of mental control is proposed to account for the intentional and counterintentional effects that result from efforts at self-control of mental states. The theory holds that an attempt to control the mind introduces 2 processes: (a) an operating process that promotes the intended change by searching for mental contents consistent with the intended state and (b) a monitoring process that tests whether the operating process is needed by searching for mental contents inconsistent with the intended state. The operating process requires greater cognitive capacity and normally has more pronounced cognitive effects than the monitoring process, and the 2 working together thus promote whatever degree of mental control is enjoyed. Under conditions that reduce capacity, however, the monitoring process may supersede the operating process and thus enhance the person's sensitivity to mental contents that are the ironic opposite of those that are intended.
... The first factor describes what is prescribed, either a change or a symptom, and the second factor describes the how or the connotation of the prescription. To illustrate factor one,Ascher and Turner (1979) prescribed a symptom by instructing insomniac clients to stay awake, whereas,Feldman, Strong, and Dancer (1982) directed clients to let themselves be depressed by concentrating on negative thoughts and avoiding cheerful places. The symptom is usually experienced by the client as an uncontrollable, spontaneous occurrence of an undesirable event and the demand to bring it about deliberately creates a "be spontaneous" paradox. ...
... We believe that seeing personal problems as natural results of the contingencies within which they are embedded, and personal goals as requiring the design of, or exposure to, new contingencies (which may, of course, require new repertoires to access), is a far more hopeful stance, in which client and consultant can work together toward clearly specified goals. Given this collaborative emphasis, we also tend to avoid interventions that depend on paradox, except where the paradoxical mechanisms can be shared with the client (Ascher & Turner, 1979). ...
In this paper the authors report on the early development of a cultural entity––Walden Fellowhip, Inc.––which was established “to explore and encourage the development of behavior and cultural practices which maximize reinforcement and minimize coercion over the long term for all persons in a manner consistent with the survival of the human and other species.� This voluntary organization maintains three primary streams of activity: self-education, consultation services, and cultural design research in the wider community. A major goal toward which involvement in all of these converge is the development of a mutually reinforcing social and verbal community among participants. Unlike an earlier paper in which this organization was conceptualized, this article is not fictional.
... 64 However, intentionally "wanting" to fall asleep is often counterproductive; therefore, paradoxical interventions are sometimes more helpful to induce sleep. 65,66 Thus, inducing sleep or extending SWS under hypnosis might bypass the explicit and voluntary intention, inducing subsequent sleep effects on a more subconscious level, not involving willing decision processes. In particular, the effects of the hypnotic suggestion were highly specific in our study: The suggestion to "sleep deeper" specifically extended duration of SWS, leaving other sleep stages unaffected. ...
Study objectives:
Slow wave sleep (SWS) plays a critical role in body restoration and promotes brain plasticity; however, it markedly declines across the lifespan. Despite its importance, effective tools to increase SWS are rare. Here we tested whether a hypnotic suggestion to "sleep deeper" extends the amount of SWS.
Design:
Within-subject, placebo-controlled crossover design.
Setting:
Sleep laboratory at the University of Zurich, Switzerland.
Participants:
Seventy healthy females 23.27 ± 3.17 y.
Intervention:
Participants listened to an auditory text with hypnotic suggestions or a control tape before napping for 90 min while high-density electroencephalography was recorded.
Measurements and results:
After participants listened to the hypnotic suggestion to "sleep deeper" subsequent SWS was increased by 81% and time spent awake was reduced by 67% (with the amount of SWS or wake in the control condition set to 100%). Other sleep stages remained unaffected. Additionally, slow wave activity was significantly enhanced after hypnotic suggestions. During the hypnotic tape, parietal theta power increases predicted the hypnosis-induced extension of SWS. Additional experiments confirmed that the beneficial effect of hypnotic suggestions on SWS was specific to the hypnotic suggestion and did not occur in low suggestible participants.
Conclusions:
Our results demonstrate the effectiveness of hypnotic suggestions to specifically increase the amount and duration of slow wave sleep (SWS) in a midday nap using objective measures of sleep in young, healthy, suggestible females. Hypnotic suggestions might be a successful tool with a lower risk of adverse side effects than pharmacological treatments to extend SWS also in clinical and elderly populations.
Insomnia is a debilitating and widespread complaint. Concern over the iatrogenic effects of pharmacological therapies has led to the development of several psychological treatments for insomnia. To clarify the effects of these treatments, 66 outcome studies representing 139 treatment groups were included in a meta-analysis. The results indicated that psychological treatments produce considerable enhancement of both sleep patterns and the subjective experience of sleep. In terms of enhancing sleep onset, active treatments were all superior to placebo therapies but did not differ greatly in efficacy. Greater therapeutic gains were available for participants who were clinically referred and who were not regular users of sedative hypnotics. Future research directions are suggested.
The effectiveness of paradoxical interventions in psychotherapy was evaluated in a meta-analysis of 12 data sets. Overall, paradoxical interventions were as effective as (but not more effective than) the typical treatment mode. However, paradoxical interventions showed relatively greater effectiveness than other interventions (a) 1 month after treatment termination and (b) with more severe cases. Finally, the analyses point to the advantage of positive connotations but raise serious doubts concerning the effectiveness of symptom prescription that does not follow a positive connotation. We offer specific research questions pertaining to the factors that mediate the differential effectiveness of paradoxical interventions.
This article outlines the evidence base for the use of paradoxical interventions (PIs) in individual psychotherapy. Often misunderstood, PIs have shown long-term (distal) impacts on clinical outcomes, yet a review of the existing literature on these interventions illustrates a trending decline in consideration and use within both research and applied settings. Definitions of PIs and their constituent elements are presented along with clinical examples. We conducted one meta-analysis comparing PIs with a placebo or control and another comparing PIs to other therapeutic methods. PIs demonstrated a large effect (d = 1.1, k = 17 studies) compared to controls and a medium effect size (d = .49, k = 17 studies) compared to other therapeutic methods. We included a review of several case studies using PIs as well. Among the salient findings, there is a lack of assessment measure to track the implementation of PIs in session or a method to track their in-session effects. Further, there is a dearth of contemporary quantitative experimental research and development of PIs. We further advocate for the development and integration of PI training and supervision into clinical education and posteducation programs, given the current data demonstrating clinical utility.
The purpose of this chapter is to provide an overview of what you might expect to find in a CBT program for insomnia. That is, what would comprise the standard treatment protocol . I have taken the perspective that the published literature provides us with the greatest confidence in knowing what is effective, and so have included, as standard, those elements of CBT that have the strongest evidence base. That said, a feature of the insomnia trials literature is that CBT has typically been evaluated as a multicomponent therapy, so discrete elements have not necessarily been investigated as fully as one might wish, and the contribution of those elements to the overall treatment effect remains largely unknown. Consequently, where a given intervention has been a common component in trials demonstrating the effectiveness of CBT, I have taken the view that there are good grounds for thinking of that intervention as part of the standard protocol. In other words, it is at the very core of CBT for insomnia. Inevitably, I have had to make some choices and some judgements in proposing this standard protocol, and I recognise that others may take a different view. My intention is that the chapter is practical, in keeping with the purpose of this book, rather than heavily referenced to source materials, so I have relied mainly on clinical guidelines, practice parameters and systematic reviews when citing evidence. It is important to note, however, that clinical trials, of which there are many, are readily accessible through these overviews and I would recommend that you look at some of those to see just how varied CBT for insomnia can be, in content, content ordering, in treatment duration and in format of delivery. There are situations, however, where I have felt it helpful, and interesting perhaps, to provide more referencing; for example, to the scientific and historical roots of CBT. I often feel that these are overlooked. It is very important to appreciate the strength, depth and longevity of our field, even if the terminology we use (and sometimes re‐brand) appears as if it is novel! Our confidence that CBT works is also based on this provenance, and the diligent work of countless clinicians and researchers over many decades. Finally, this chapter is provided as a platform upon which other chapters may build. By presenting this standard protocol, focussed primarily in relation to adults with insomnia, applications of CBT to other populations, age groups and circumstances, protocol variations, and emerging approaches to therapeutics can compare, contrast and evolve through the course of the textbook. I have also tried to write as much as possible in plain language, and to share personal accounts of how I would deliver CBT, to make this chapter as clinically informative as possible. If you would like further insight into my approach to the actual delivery of CBT‐I, I would refer you to two recent books, one for patients (Espie, 2021) and the other for clinicians (Espie, 2022).
Background:
Control interventions in randomised trials provide a frame of reference for the experimental interventions and enable estimations of causality. In the case of randomised trials assessing patients with mental health disorders, many different control interventions are used, and the choice of control intervention may have considerable impact on the estimated effects of the treatments being evaluated.
Objectives:
To assess the benefits and harms of typical control interventions in randomised trials with patients with mental health disorders. The difference in effects between control interventions translates directly to the impact a control group has on the estimated effect of an experimental intervention. We aimed primarily to assess the difference in effects between (i) wait-list versus no-treatment, (ii) usual care versus wait-list or no-treatment, and (iii) placebo interventions (all placebo interventions combined or psychological, pharmacological, and physical placebos individually) versus wait-list or no-treatment. Wait-list patients are offered the experimental intervention by the researchers after the trial has been finalised if it offers more benefits than harms, while no-treatment participants are not offered the experimental intervention by the researchers.
Search methods:
In March 2018, we searched MEDLINE, PsycInfo, Embase, CENTRAL, and seven other databases and six trials registers.
Selection criteria:
We included randomised trials assessing patients with a mental health disorder that compared wait-list, usual care, or placebo interventions with wait-list or no-treatment .
Data collection and analysis:
Titles, abstracts, and full texts were reviewed for eligibility. Review authors independently extracted data and assessed risk of bias using Cochrane's risk of bias tool. GRADE was used to assess the quality of the evidence. We contacted researchers working in the field to ask for data from additional published and unpublished trials. A pre-planned decision hierarchy was used to select one benefit and one harm outcome from each trial. For the assessment of benefits, we summarised continuous data as standardised mean differences (SMDs) and dichotomous data as risk ratios (RRs). We used risk differences (RDs) for the assessment of adverse events. We used random-effects models for all statistical analyses. We used subgroup analysis to explore potential causes for heterogeneity (e.g. type of placebo) and sensitivity analyses to explore the robustness of the primary analyses (e.g. fixed-effect model).
Main results:
We included 96 randomised trials (4200 participants), ranging from 8 to 393 participants in each trial. 83 trials (3614 participants) provided usable data. The trials included 15 different mental health disorders, the most common being anxiety (25 trials), depression (16 trials), and sleep-wake disorders (11 trials). All 96 trials were assessed as high risk of bias partly because of the inability to blind participants and personnel in trials with two control interventions. The quality of evidence was rated low to very low, mostly due to risk of bias, imprecision in estimates, and heterogeneity. Only one trial compared wait-list versus no-treatment directly but the authors were not able to provide us with any usable data on the comparison. Five trials compared usual care versus wait-list or no-treatment and found a SMD -0.33 (95% CI -0.83 to 0.16, I² = 86%, 523 participants) on benefits. The difference between all placebo interventions combined versus wait-list or no-treatment was SMD -0.37 (95% CI -0.49 to -0.25, I² = 41%, 65 trials, 2446 participants) on benefits. There was evidence of some asymmetry in the funnel plot (Egger's test P value of 0.087). Almost all the trials were small. Subgroup analysis found a moderate effect in favour of psychological placebos SMD -0.49 (95% CI -0.64 to -0.30; I² = 53%, 39 trials, 1656 participants). The effect of pharmacological placebos versus wait-list or no-treatment on benefits was SMD -0.14 (95% CI -0.39 to 0.11, 9 trials, 279 participants) and the effect of physical placebos was SMD -0.21 (95% CI -0.35 to -0.08, I² = 0%, 17 trials, 896 participants). We found large variations in effect sizes in the psychological and pharmacological placebo comparisons. For specific mental health disorders, we found significant differences in favour of all placebos for sleep-wake disorders, major depressive disorder, and anxiety disorders, but the analyses were imprecise due to sparse data. We found no significant differences in harms for any of the comparisons but the analyses suffered from sparse data. When using a fixed-effect model in a sensitivity analysis on the comparison for usual care versus wait-list and no-treatment, the results were significant with an SMD of -0.46 (95 % CI -0.64 to -0.28). We reported an alternative risk of bias model where we excluded the blinding domains seeing how issues with blinding may be seen as part of the review investigation itself. However, this did not markedly change the overall risk of bias profile as most of the trials still included one or more unclear bias domains.
Authors' conclusions:
We found marked variations in effects between placebo versus no-treatment and wait-list and between subtypes of placebo with the same comparisons. Almost all the trials were small with considerable methodological and clinical variability in factors such as mental health population, contents of the included control interventions, and outcome domains. All trials were assessed as high risk of bias and the evidence quality was low to very low. When researchers decide to use placebos or usual care control interventions in trials with people with mental health disorders it will often lead to lower estimated effects of the experimental intervention than when using wait-list or no-treatment controls. The choice of a control intervention therefore has considerable impact on how effective a mental health treatment appears to be. Methodological guideline development is needed to reach a consensus on future standards for the design and reporting of control interventions in mental health intervention research.
Introduction:
The purpose of this systematic review is to provide supporting evidence for a clinical practice guideline on the use of behavioral and psychological treatments for chronic insomnia disorder in adult populations.
Methods:
The American Academy of Sleep Medicine commissioned a task force of nine experts in sleep medicine. A systematic review was conducted to identify randomized controlled trials that addressed behavioral and psychological interventions for the treatment of chronic insomnia disorder in adults. Statistical analyses were performed to determine if the treatments produced clinically significant improvements in a range of critical and important outcomes. Finally, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to evaluate the evidence for making specific treatment recommendations.
Results:
The literature search identified 1274 studies; 124 studies met the inclusion criteria; 89 studies provided data suitable for statistical analyses. Evidence for the following interventions are presented in this review: Cognitive Behavioral Therapy for Insomnia (CBT-I), Brief Therapies for Insomnia (BTIs), stimulus control, sleep restriction therapy, relaxation training, sleep hygiene, biofeedback, paradoxical intention, intensive sleep retraining and mindfulness. This review provides a detailed summary of the evidence along with the quality of evidence, the balance of benefits versus harms, patient values and preferences, and resource use considerations.
Study Objectives
Our goal was to compare Brief Behavioral Treatment for Insomnia (BBTI) to a Progressive Muscle Relaxation Training (PMRT) control condition among veterans with insomnia, examining psychosocial functioning as a primary outcome and sleep-related outcomes, mood, cognition, and pain as secondary outcomes.
Methods
Veterans were randomly assigned to either BBTI or PMRT (N=91; 24-74 years; M=49 years). BBTI consisted of two in-person (60-minute and 30-minute sessions) and two telephone sessions (20-minutes each), and the PMRT control condition was matched to BBTI for session duration and type. Veterans were assessed through clinical interview at baseline and self-report measures at pre- mid- and post-treatment, as well as six-month follow-up for the BBTI condition to assess sustained response. Measures also included continuous sleep monitoring with sleep diary.
Results
Intent-to-treat analyses demonstrated that individuals who completed BBTI vs. PMRT reported greater improvements in work, home, social and cognitive functioning, insomnia symptom severity, mood, and energy. Improvements in psychosocial functioning, insomnia symptoms and mood were maintained six-months following BBTI treatment completion.
Conclusions
Veterans who received BBTI improved and maintained gains in psychosocial functioning, insomnia and mood. BBTI is a treatment that can be implemented in primary care, mental health, or integrated care settings and provide symptom relief and improved functioning among those with insomnia, one of the most commonly reported mental health problems among veterans.
This systematic review focuses on three themes: 1) the nature of pre-sleep cognitive activity in good sleepers and individuals with insomnia, 2) the links between measures of pre-sleep cognitive activity and sleep onset latency (SOL) or insomnia, and 3) the effect of manipulating pre-sleep cognitive activity on SOL or insomnia. Regarding the first theme, mentation reports have been collected in a sleep laboratory, with an ambulatory monitoring device, or using a voice-activated tape-recorder. Normal transition to sleep is characterized by sensorial imagery, deactivation of higher cognitive processes, and hallucinations. Moreover, pre-sleep thoughts in individuals with insomnia frequently relate to planning or problem-solving, and are more unpleasant than in good sleepers. Regarding the second theme, twelve questionnaires and three interviews were identified. Insomnia is associated with more thoughts interfering with sleep, counterfactual processing, worries, maladaptive thought control strategies, covert monitoring, and cognitive arousal. Regarding the third theme, several strategies have been tested: mental imagery, hypnosis, paradoxical intention, articulatory suppression, ordinary suppression, and distraction. Their effect is either beneficial, negligible, or detrimental. Future research should focus on the mechanisms through which some forms of cognitive activity affect sleep onset latency.
Insomnia is a condition that affects nearly everyone at some time, but about one third of the population suffers from the problem chronically (Bixler, Kales, Soldatos, & Healey, 1979; Kales & Kales, 1984). It is the most common sleep-related complaint and is associated with a wide variety of psychiatric and physical disorders (Bixler et al., 1979; Bixler, Kales, & Soldatos, 1979; Kales & Kales, 1984). The alleviation of insomnia is a major concern for public health practitioners, but the available treatments, as they are usually prescribed and implemented, are unreliable and often ineffective. To treat the complaint of insomnia effectively, practitioners must be aware of the variety of causes and manifestations of this complaint and its psychosocial effects. Too often a unidimensional prescriptive approach is taken without adequate consideration of the causes or effects of the problem itself. This approach is marginally effective at best and can lead to more serious or counterproductive results exacerbating the original problem unnecessarily.
The essence of a cognitive model of psychopathology is the implication of multiple cognitive processes (including schematic, attentional, and perceptual biases) that predispose and perpetuate a given disorder. Considerable research has amassed to support this model in insomnia; that is, people with insomnia have a range of cognitive-emotional processes that make it more likely for the insomnia to occur and continue (Behav Res Ther 40:869–893, 2002). Harvey (Behav Res Ther 40:869–893, 2002) presents a comprehensive contemporary cognitive model of insomnia, which includes a range of sleep-interfering cognitive processes including beliefs, perception, and attention. We discuss each component of Harvey’s Cognitive Model of Insomnia and provide evidence in support of such a model. This chapter sets the stage for a detailed discussion of cognitive strategies in the subsequent chapter.
Intense psychological pain and a major disruption of daily life invariably accompany chronic insomnia. These patients feel an urgent need for help. Fear and anger, in response to not controlling sleep, often lead to feelings of powerlessness, despair, and increasing frustration. Unfortunately, these emotional reactions are instrumental in transforming transient insomnia into chronic insomnia. Emotional stress occasionally brings transient sleeplessness to almost everyone; however, an intense emotional reaction to sleeplessness combines with conditioning or learning patterns to perpetuate temporary sleeplessness into agonizing and life-disruptive chronic insomnia.
Insomnie ist ein Mangel an Schlafqualität oder Schlafquantität. Der Begriff Insomnie suggeriert komplette Schlaflosigkeit. Er beschreibt jedoch zumeist eine graduelle Störung und damit eine Hyposomnie. Eine Insomnie entsteht aus einem defizitären Mißverhältnis zwischen Schlafbedürfnis und Schlafvermögen. Sie ist auch ein subjektives Phänomen und damit die individuelle Wahrnehmung eines gestörten Schlafes (APA 1987; ASDA 1990; ASDC 1979; Buysse u. Reynolds 1990; Kales u. Kales 1984; Parkes 1985; Soldatos et al. 1979). Eine Insomnie bekommt die Wertigkeit einer Diagnose, wenn die Beeinträchtigung des Schlafes die Hauptbeschwerde darstellt, die Insomnie in andere physische oder psychische Störungen überleitet oder diese verschlimmert. Sie wird als manifeste Erkrankung angesehen, wenn sich die Beschwerden innerhalb eines Monats mindestens dreimal pro Woche wiederholen und beim Patienten Einbußen im Wohlbefinden und in der Leistungsfähigkeit am Tage auftreten (APA 1987).
Insomnien entstehen aus einem Mißverhältnis zwischen Schlafbedürfnis und Schlafvermögen. Sie stellen einen Mangel an Schlafqualität oder Schlafquantität dar. Sie sind auch ein subjektives Phänomen und damit die individuelle Wahrnehmung eines gestörten Schlafs (ASDC 1979; Soldatos et al. 1979; Kales u. Kales 1984; Parkes 1985; APA 1987; ASDA 1990; Buysse u. Reynolds 1990).
Despite a well-documented record of notable success in the treatment of neuroses, behaviour therapy is little taught in academic departments. A major reason for this appears to be the existence of an unending stream of misinformation about it. This paper describes the essential features of modern behaviour therapy of the neuroses, and the range of its therapeutic effects. It outlines some major sources of misinformation and their stifling effect on the academic spread of behaviour therapy.
During the past 10 years, there has been an explosion of research on sleep and sleep disorders. Much has been learned about the causes and treatment of sleep disorders, including insomnia, sleep apnea, and narcolepsy. In addition, alterations in sleep patterns are so commonly associated with some disorders (e.g, affective disorders, post-traumatic stress disorder, and fibrositis) that they are used as diagnostic criteria for those disorders. More generally, we are all affected by the amount and quality of the sleep we obtain. Sleep has broad, systemic effects on mood, performance, and physical functioning. Thus, an understanding of sleep is essential to a complete understanding of normal and abnormal behavior.
Sleep taken at regular intervals has been an indispensable part of human and virtually all mammalian life. Yet its ephemeral and delicate nature remains poised to introduce the pain of insomnia when strained by momentous, but more often, trivial irritants. An extra sip of coffee, an awkward glance by a supervisor, or a barely audible noise in the home at bedtime may steal sleep from us. Left in its place is frustration and the nagging heritage of inadequate sleep that haunts us the next day.
Although average humans spend about one-third of their lives, or about 25 years, asleep, we actually know very little about the mechanisms of sleep, its induction, maintenance, or termination, and even less about the functions it serves. We do know that sleep is not the mere absence of wakefulness. It is, rather, an active phenomenon requiring some effort to maintain, but effort most people would call “restful.” We also know that sleep is not a unitary phenomenon and is characterized instead by diverse behavioral, physiological, and electrographic states.
Approaches to interpersonal helping continue to proliferate with literally hundreds of overlapping and competing models currently on the clinical scene. Although therapists, researchers, and clinicians have striven diligently to identify which models may be best suited for which clients, problems, and so forth, these efforts have as yet produced little that is definitive, at least little that is backed by persuasive evidence. These developments have sparked a continuing movement toward eclecticism in practice as well as the rise of “integrative” practice models. The essential function of integrative models is to provide ways of synthesizing this diversity for purposes of practice, training, and research. Although the syntheses they offer are inevitably partial and selective, they can present theoretical horizons and technical combinations not found in single models.
A large body of research over the past 20 years has confirmed the value and benefits of SST for people with schizophrenia. The concepts of self-esteem and SST are closely linked, and a number of recent studies demonstrate the benefit of focusing on self-esteem within different diagnostic areas, including the schizophrenic population, as a way to reduce psychopathology and promote coping strategies and social skills within the schizophrenic population. A comprehensive model of SST training is described in phases as a method aimed to improve self-efficacy and quality of life, and the procedure of self-esteem training is suggested as a supplement to SST.
Confusion and controversy surrounding the area of “self-management” stem from a failure to consider the multi-level nature of self-management and a lack of terminological consensus among researchers. The current paper analyzes both conceptual and empirical objections to self-management. Included in the discussion is a description of the effectiveness of self-management as well as an attempt at incorporation of self-management within the overall radical behavioral framework.
Insomnia is a condition characterized by subjective complaints of insufficient sleep and poor daytime functioning. Objective measures of sleep and daytime functioning, however, seldom show evidence of a similar degree of dysfunction. Most insomniacs, for example, do not suffer from sleep deprivation or daytime sleepiness. This discrepancy between subjective and objective measures of sleep and daytime functioning suggests that cognitive factors may play a central role in persistent insomnia. In particular, it is argued that fears about insufficient sleep and its adverse daytime consequences tend to interfere with sleep, thereby causing a vicious cycle which serves to maintain the insomnia. It is also argued that perfectionist standards and other dysfunctional beliefs may predispose people to these kinds of fears. Finally, existing models for cognitive-behavioural treatment of insomnia are criticized for being almost exclusively focused on the night-time aspects of insomnia. If insomnia is maintained by various kinds of vicious cycles involving fears, beliefs, and standards with regard to daytime functioning, these daytime aspects of insomnia should receive more attention in cognitive-behavioural treatment.
The aim of this study was to investigate the effects of intention to fall asleep on sleep quality in good sleepers using polysomnographic and subjective nap parameters. We hypothesized that high intention to sleep would lead to arousal, worsening sleep quality. A counterbalanced 2 × 2 experimental design with one intra-individual (neutral versus motivating instruction) and one inter-individual (instruction sequence) variable was used. Thirty-three good sleepers (22 females; mean age: 24.1 ± 8.4 years) each attended two 1-h daytime polysomnographic recording sessions in the laboratory. When providing motivating instruction, the experimenter insisted on the importance of falling asleep as quickly as possible and promised a financial reward. Compared with neutral instruction, motivating instruction was associated with increased waking after sleep onset, number of awakenings and arousal index during napping. No relationship between instruction and subjective nap appraisal was found. The effect of high intention on sleep fragmentation remained significant after controlling for habitual napping, depression, anxiety and sleepiness. Thus, our findings suggest that high intention to fall asleep worsened sleep quality, especially in terms of sleep fragmentation, in good sleepers.
Describes 2 techniques of logotherapy, paradoxical intention and dereflection, utilizing a number of case reports. The first attempts to break a self-sustaining vicious circle involving anticipating anxiety: a symptom evokes a phobia and the phobia provokes the symptoms, which reinforces the phobia. In phobic cases patients display fear of fear, while obsessive-compulsive patients show fear of themselves. Phobics attempt to flee from the fear, while obsessives try to fight against their obsessions and compulsions. Paradoxical intention is a process whereby the patient is encouraged to do the things he fears or to wish for them to happen. The use of this technique by behavioral therapists is discussed. Dereflection has been developed for persons with sexual disorders (impotence and frigidity), in which the patient's fight for sexual pleasure becomes an obstacle to achieving it. The therapist advises against intercourse and breaks the vicious circle of expectation of pleasure, striving, and disappointment. (67 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Assigned 48 sleep-disturbed college students to 1 of 4 conditions: relaxation training, single-item desensitization, placebo, and no treatment. Counterdemand instructions were given during the 1st 3 sessions: Ss were told that improvement in sleep disturbance would not occur until after the 4th session. Relaxation and desensitization procedures produced significantly greater reports of improvement in latency of sleep onset than placebo and no treatment during the counterdemand period, while all 3 treated groups reported significantly greater improvement than no treatment after the 4th (positive demand) session. Results support the effectiveness of relaxation therapy in the treatment of moderate insomnia. Demand characteristics may contribute to S reports, but the use of counterdemand instructions allows for valid comparisons among therapy conditions.
PHYSIOLOGICAL, PERSONALITY, AND EEG SLEEP PATTERNS OF 16 POOR-SLEEP GROUP (PSG) SS WERE COMPARED WITH 16 GOOD-SLEEP GROUP (GSG) SS. COMPARED WITH GOOD SLEEPERS, POOR SLEEPERS HAD LESS SLEEP TIME, A HIGHER PROPORTION OF STAGE 2 SLEEP, MARKEDLY LESS REM SLEEP DESPITE A SIMILAR NUMBER OF REM PERIODS, MORE AWAKENINGS, AND REQUIRED MORE TIME TO FALL ASLEEP. SIGNIFICANT PHYSIOLOGICAL DIFFERENCES BETWEEN THE GROUPS WERE OBSERVED DURING ALL STAGES OF SLEEP AND DURING A PRESLEEP PERIOD. PERSONALITY TEST RESULTS CLEARLY INDICATED A MUCH HIGHER PROBABILITY OF SYMPTOMATIC COMPLAINTS AMONG POOR SLEEPERS AS WELL AS A STRONG POTITIVE RELATIONSHIP BETWEEN DREAMING AND INDEXES OF PSYCHOPATHOLOGY. THIS STUDY DID NOT RESOLVE CAUSE AND EFFECT RELATIONSHIPS AMONG PHYSIOLOGICAL VARIABLES, PERSONALITY MEASURES, AMOUNT OF DREAMING, AND GOOD AND POOR SLEEP; HOWEVER, SIGNIFICANT EEG, PHYSIOLOGICAL, AND PSYCHOLOGICAL DIFFERENCES WERE DEMONSTRATED. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Assessed the effectiveness of treatment programs based on progressive relaxation, stimulus control, and paradoxical intention in the context of sleep difficulties for 50 volunteer Ss. The results indicate that each of the therapeutic procedures significantly reduced sleep complaints in contrast to placebo and waiting list control groups. No differences were observed among the 3 active techniques. (1½ p ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Although most cases of psychogenic urinary retention can be ameliorated by a program composed of various behavioral techniques, there is a small percentage of cases which resists the behavioral treatment of choice. The present multiple case paper focused on the treatment of several resistant cases of functional urinary retention. Following a two week baseline period, each individual was exposed to eight weekly behavioral sessions. Whereas most cases of urinary retention have significantly improved by this time, the five individuals chosen for the present study were dissatisfied with their progress. Thus, following the eighth week, paradoxical intention was employed. Within six weeks treatment for the urinary problem was terminated as all clients were comfortable with this aspect of their daily behavior. It was hypothesized that cases of psychogenic urinary retention which resist behavioral techniques are possibly exacerbated by performance anxiety. Such anxiety can be efficiently handled by paradoxical intention.
Paradoxical intention as a component in the behavioral treatment of sleep onset insomnia: A case study
- Ascher
Paradoxical intention
- Ascher