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How pa adoxical is ‘pa adoxical’ ou come? : Di e en pa hways and implica ions
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Wahls öm, Ja l
Wahls öm, J. (2021). How pa adoxical is ‘pa adoxical’ ou come? : Di e en pa hways and
implica ions. Eu opean Jou nal o Psycho he apy, Counselling and Heal h, 23(2), 222-236.
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How pa adoxical is ‘pa adoxical’ ou come?
Di e en pa hways and implica ions
Ja l Wahls öm
To ci e his a icle: Ja l Wahls öm (2021): How pa adoxical is ‘pa adoxical’ ou come?
Di e en pa hways and implica ions, Eu opean Jou nal o Psycho he apy & Counselling, DOI:
10.1080/13642537.2021.1923052
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How pa adoxical is ‘pa adoxical’ ou come? Di e en
pa hways and implica ions
Ja l Wahls öm
Depa men o Psychology, Uni e si y o Jy äskylä, Jy askyla, Finland
ABSTRACT
The p esen special issue includes single and mul iple case s udies which
epo on he phenomenon o ‘pa adoxical’ ou comes in psycho he apy,
ope a ionalized as disco dan ou come assessmen s wi hin he same case. In
an a emp o ind g ound o my published esponse, I endea o ed o
jux aposi ion he cases om he di e en s udies, and by doing ha gain an
o e iew o he con ibu ions and a gumen s. As a esul o ha exe cise,
I sugges h ee di e en ypes o pa adoxical ou come wi h di e en pa h-
ways and implica ions. Discussing he concep o ‘illuso y men al heal h’ as
a possible explana ion o pa adoxical ou come, I sugges ha sel - a ings
wi hin a nonclinical ange, gi en by esponden s assessed as psychologically
dis essed, could be pe cei ed as ‘genuine’ ma ke s o a ole able le el o
coping and symp om elie , no only as an indica ion o a de ensi e a i ude.
I conclude ha i migh be mo e ad an ageous o ela e ‘pa adoxical’ ou -
comes o aspec s o he he apeu ic p ocess, a he han o psychological
disposi ions o he clien s.
CONTACT Ja l Wahls öm [email p o ec ed]
This manusc ip is in ended as a published esponse o he special issue on pa adoxical ou come in
psycho he apy and illuso y men al heal h, edi ed by John McLeod.
EUROPEAN JOURNAL OF PSYCHOTHERAPY & COUNSELLING
h ps://doi.o g/10.1080/13642537.2021.1923052
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Wie pa adox is das „pa adoxe“ E gebnis? Un e schiedliche
Wege und Implika ionen
ABSTRAKT
Die o liegende Sonde ausgabe en häl Einzel- und Meh ach alls udien,
die übe das Phänomen „pa adoxe “ E gebnisse in de Psycho he apie
be ich en und als nich übe eins immende E gebnisbewe ungen inne -
halb desselben Falls ope a ionalisie we den. Um einen G und ü meine
e ö en lich e An wo zu inden, bemüh e ich mich, die Fälle aus den
e schiedenen S udien nebeneinande zu s ellen und mi so einen
Übe blick übe die Bei äge und A gumen e zu e scha en. Als E gebnis
diese Übung schlage ich d ei e schiedene A en on pa adoxen
E gebnissen mi un e schiedlichen Wegen und Implika ionen o . Ich
disku ie e das Konzep de „illuso ischen psychischen Gesundhei “
als mögliche E klä ung ü das pa adoxe E gebnis und schlage o , dass
Selbs einschä zungen inne halb eines nich klinischen Be eichs, die on
Be ag en als psychisch p oblema isch einges u we den, als „ech e“
Ma ke ü ein ole ie ba es Bewäl igungsni eau wah genommen we den
könn en und Linde ung de Symp ome, nich nu als Hinweis au eine
de ensi e Hal ung sind. Ich komme zu dem Schluss, dass
es mögliche weise o eilha e is , „pa adoxe“ E gebnisse mi Aspek en
des he apeu ischen P ozesses in Beziehung zu se zen, als mi psycho-
logischen Disposi ionen de Klien en
¿Qué an pa adójico es el esul ado “pa adójico”? Di e en es
caminos e implicaciones
RESUMEN
La ac ual cues ión especí ica incluye es udios de un caso único y múl iple
que in o man sob e el enómeno de los esul ados ‘pa adójicos’ en la
psico e apia, los cuáles lle an a la p ác ica esul ados disco dan es en la
e aluación de un mismo caso. En un in en o de encon a espues a en el
ámbi o de la publicación, se ealizó un g an es ue zo pa a yux apone los
casos de los di e en es es udios, y al hace lo ob ene una isión gene al
de las apo aciones y a gumen os. Como esul ado de ese eje cicio
sugie o es ipos di e en es de esul ados pa adójicos con di e en es
ías e implicaciones. Al discu i el concep o de ‘salud men al iluso ia’
como una posible explicación pa a el esul ado pa adójico, sugie o que
las e aluaciones den o de un ango no clínico, dada po los encues ados
e aluados con p oblemas psicológicos, pod ían se pe cibidas como ma -
cado es ‘genuinos’ de un ni el ole able de a on amien o y ali io de los
sín omas, no sólo como una indicación de una ac i ud de ensi a.
Concluyo que pod ía se más en ajoso elaciona los esul ados
‘pa adójicos’ con aspec os del p oceso e apéu ico, en luga de con las
disposiciones psicológicas de los clien es.
2J. WAHLSTRÖM
Quan o è pa adossale il isul a o “pa adossale”? Di e en i
pe co si e implicazioni
ABSTRACT
Il p esen e nume o speciale include s udi di casi singoli e mul ipli che
ipo ano il enomeno degli esi i ‘pa adossali’ in psico e apia, ope aziona-
lizza i come disco dan i p ocedu e di assessmen dei isul a i all’in e no
dello s esso caso. Nel en a i o di o a e una base pe la mia ispos a
e pubblicazione, ho ce ca o di gius appo e i casi dei di e si s udi,
o enendo così una pano amica dei con ibu i e degli a gomen i. Come
isul a o di ciò, sugge isco e di e si ipi di isul a i pa adossali con
pe co si e implicazioni di e en i. Discu endo il conce o di `` salu e
men ale illuso ia ‘‘ come possibile spiegazione di un esi o pa adossale,
sugge isco che le alu azioni di sé all’in e no di un in e allo non clinico,
o ni e dagli in e is a i alu a i come dis u ba i psicologici, possano
esse e pe cepi e come indica o i `` genuini ‘‘ di un li ello app ezzabile
di coping e sollie o dai sin omi e non solo come indicazione di un
a eggiamen o di ensi o. Concludo che po ebbe esse e più an aggioso
me e e in elazione i isul a i ‘pa adossali’ con gli aspe i del
p ocesso e apeu ico, piu os o che con le disposizioni psicologiche dei
clien i.
Dans quelle mesu e un ésul a pa adoxal es -il pa adoxal?
Di é en es oies e implica ions
Ce numé o spécial comp end des é udes de cas uniques e mul iples qui
on é a du phénomène des ésul a s « pa adoxaux » en psycho hé apie
se epé an en p a ique comme un ésul a é alua i disco dan au sein
du même cas. Dans un souci de ou e un poin d’appui pou mon
ex e, je me suis e o cé de jux apose les cas d’é udes di é en es e
ainsi de gagne une ue d’ensemble des con ibu ions e des a gumen s.
À pa i de ce exe cice, je suggè e ois ypes dis inc s de ésul a s
pa adoxaux emp un an des oies e ayan des implica ions di é en es.
En ce qui conce ne le concep de « san é men ale illusoi e » en an
qu’explica ion possible du ésul a pa adoxal, je suggè e que les
au oé alua ions au sein d’un é en ail non clinique données pa les pe -
sonnes in e ogées es imées psychologiquemen pe u bées, pou aien
ê e pe çues comme un ma queu é i able d’un ni eau olé able de
ges ion e de soulagemen du symp ôme e pas seulemen l’indica eu
d’une a i ude dé ensi e. Je conclus qu’il aud ai peu -ê e mieux me e
les ésul a s « pa adoxaux » en ela ion a ec des aspec s du a ail
hé apeu ique plu ô qu’a ec les disposi ions psychologiques des clien s.
EUROPEAN JOURNAL OF PSYCHOTHERAPY & COUNSELLING 3

Πόσο παράδοξο είναι το «παράδοξο» αποτέλεσμα
Διαφορετικές οδοί και εφαρμογές
ΠΕΡΊΛΗΨΗ
Το παρόν ειδικό τεύχος περιλαμβάνει μεμονωμένες και πολλαπλές μελέτες
περίπτωσης, οι οποίες αναφέρονται στο φαινόμενο των «παράδοξων»
αποτελεσμάτων στην ψυχοθεραπεία, τα οποία ορίζονται λειτουργικά ως
ασύμφωνες αξιολογήσεις έκβασης μέσα στην ίδια την περίπτωση. Σε μια
προσπάθεια να βρεθεί έδαφος για τη δημοσιευμένη απάντησή μου,
επιχείρησα να αντιπαραθέσω τις περιπτώσεις από τις διάφορες μελέτες και
κάνοντας αυτό να αποκτήσουμε μια επισκόπηση των συνεισφορών και των
επιχειρημάτων. Ως αποτέλεσμα αυτής της άσκησης προτείνω τρεις
διαφορετικούς τύπους παράδοξου αποτελέσματος με διαφορετικές οδούς και
συνέπειες. Συζητώντας την έννοια της «ψευδαίσθησης της ψυχικής υγείας», ως
μια πιθανή εξήγηση για το «παράδοξο αποτέλεσμα», προτείνω ότι οι αυτό-
αναφορές σε μη-κλινικό φάσμα, που δίνονται από ερωτηθέντες που
κατατάσσονται ως ψυχολογικά επιβαρυμένοι θα μπορούσαν να εκληφθούν ως
«γνήσιοι» δείκτες ενός αποδεκτού επιπέδου λειτουργικότητας και ανακούφισης
συμπτωμάτων και όχι μόνο σαν ένδειξη αμυντικής στάσης. Καταλήγω στο
συμπέρασμα ότι θα μπορούσε να είναι πιο συμφέρον το «παράδοξο» των
αποτελεσμάτων να σχετίζεται με πτυχές της θεραπευτικής διαδικασίας, και όχι
με τις ψυχολογικές διαθέσεις των πελατών.
ARTICLE HISTORY Recei ed 4 Oc obe 2020; Accep ed 29 Ma ch 2021
KEYWORDS Pa adoxical ou come; illuso y men al heal h; sel - a ing; case s udy
SCHLÜSSELWÖRTER pa adoxes E gebnis; illuso ische psychische Gesundhei ; Selbs einschä zung;
Falls udie
PALABRAS CLAVE esul ado pa adójico; salud men al iluso ia; e aluación; caso p ác ico
PAROLE CHIAVE esi o pa adossale; salu e men ale illuso ia; au o alu azione; s udio del caso
MOTS-CLÉS ésul a s pa adoxaux; san é men ale illusoi e; au oé alua ion; é ude des cas
ΛΈΞΕΙΣ-ΚΛΕΙΔΙΆ παράδοξο αποτέλεσμα♦; ψευδαίσθηση ψυχικής υγείας♦; αυτό-αναφορά♦; Μελέτη
περίπτωσης
Clinical ials, app aising he e icacy o psycho he apy and counseling, as
well as na u alis ic s udies, e alua ing hei e ec i eness, epea edly epo
60% o mo e o a o able ou come o clien s in ol ed in hese ea men s
(Ba kham e al., 2012; Knek e al., 2016; Wampold & Imel, 2015) . Such
judgmen s a e usually made on he basis o sel - epo s gi en by clien
pa icipan s on a ing o ms, designed o measu e indica ions o symp oms
o speci ic men al diso de s o o mo e b oadly expe ienced psychological
dis ess. These measu es usually de ine cu o le els o sco es laying in
a ange conside ed o show ha he indi idual exhibi s an amoun o
symp oms o oubles implying a need o clinical in e en ions. Fa o able
change can hen be de ined as clinically signi ican and eliable i he espon-
den ’s sco es mo e om he clinical ange (unde o o e he cu o -line
4J. WAHLSTRÖM
depending on he di ec ion o he scale) and diminish (o inc ease) wi h
a p ede e mined numbe o poin s on he scale (enough o ensu e ha he
change is no a esul o chance) (Jacobson & T uax, 1991). I he cu o -line
is no c ossed bu he change in poin s is big enough, wha you ha e is
eliable change.
Sco es on sel - epo ins umen s a e also inc easingly used o moni o
he cou se o ongoing psychological in e en ions (Lambe e al., 2018; Lu z
e al., 2015). When clien s epea edly a egula in e als epo on hei
subjec i e expe ience o symp oms o oubles, esea che s o p ac icing
clinicians can e alua e whe he he p og ess o he he apy is ‘on ack’,
ha is, whe he i ollows an expec ed ajec o y as de e mined by esea ch
da a om la ge pools o cases. Usually, hose expec ed cou ses ollow mo e
o less linea o sligh ly cu ed p og essions, di e sions om which a e
conside ed as indica ions ha he indi idual ea men is no ‘on ack’,
and some co ec i e ac ions should be aken.
The logic behind his me hodological app oach o assess he ou come o
psychological in e en ions, o moni o hem, is basically qui e s aigh o -
wa d, and he use o sel - epo ins umen s a ela i ely simple and cos -
e ec i e al e na i e o o he o ms o assessmen . S ill, ques ions a ise. Wha
i di e en scales gi e di e en indica ions? Wha i he esponden , know-
ingly o no -knowingly, gi es misleading poin s o he i ems on he scale, ha
is, poin s ha do no co espond o his o he genuine expe ience? Wha i
he i ems a e wo ded in a way ha has no meaning o he esponden o
a di e en meaning o him o he han he one in ended by he cons uc o s
o he scale? Wha i he esponden ’s own expe ience, as indica ed by his o
he esponses o he i ems on he scales, does no co espond o obse a ions
and imp essions o o he s, be hey close ela ions o p o essionals in ol ed in
ea men o esea ch?
These kinds o ques ions a e he conce ns o he p esen special issue o
he Eu opean Jou nal o Psycho he apy and Counselling. The issue includes
one in oduc o y ex (McLeod, 2021) and ou empi ical esea ch pape s.
Wha he pape s a leas ha e in common is ha hey all employ some kind o
a quali a i e case s udy design. O he wise, hey app oach he hema ic o he
special issue om qui e di e se angles.
In his published esponse o he special issue, I ocus on he ques ion o
possible di e en in e p e a ions o he meaning o ‘pa adoxical’ ou come and
make some commen s on he concep o ‘illuso y men al heal h’ as an explana-
ion o he phenomenon– he wo main hemes o he issue. I do his by
sugges ing a ca ego iza ion o he cases p esen ed in he di e en pape s on
he basis o he ype o supposed pa adoxical ou come and a compa ison o he
cases wi hin each ca ego y. I o e some ideas on wha common ea u es he
he apy p ocesses in he cases wi hin he same ca ego y migh ha e p esen ed,
based on some no ions om quali a i e p ocess psycho he apy esea ch. The e
EUROPEAN JOURNAL OF PSYCHOTHERAPY & COUNSELLING 5
would, ce ainly, ha e been much o commen on he indi idual pape s om
he pe spec i e o he pa icula esea ch ques ions and me hodological
app oaches o each o hem bu space does no allow o ha .
Pa adoxical ou come and illuso y men al heal h
The e a e wo main hemes in his special issue. One conce ns ‘pa adoxical’
ou comes in psycho he apy, ha is he phenomenon o disco dan ou come
assessmen s wi hin he same case. The second heme deals wi h he concep
o ‘illuso y men al heal h’, he no ion ha people, o di e en easons, may
hold up a p e ense o psychological well-being, while ‘ac ually’–a leas in he
eyes o o he s–no be unc ioning so well a all.
A pa adoxical ou come may mani es i sel as a disc epancy be ween wo
o mo e assessmen me hods, one showing an a ainmen o ea men goals
and ano he a ailu e, o an unexpec ed cou se o he ea men p ocess,
no ably when he clien mo es om he nonclinical o he clinical ange o
he assessmen measu e. Ins ances whe e he ea men , on an ou come
measu e, is assessed o be success ul bu he clien is unsa is ied wi h he
p ocess can also be coun ed o as pa adoxical ou comes.
The empi ical pape s included in his special issue (De Sme e al., 2021;
K i zo e al., 2021; Tho esen e al., 2021; Wa d & McLeod, 2021) epo on
al oge he se en (7) cases in which he ou come could be de ined as pa a-
doxical (I ha e coun ed one om he pape on cases epo ing ailu es in
he apy by K i zo e al.). Acco ding o he ype o pa adoxical ou come,
hese cases may be g ouped as ollows ( he case J.J. is allo ed in o wo
ca ego ies acco ding o he phase o he he apy):
Type A: No change on sel - a ing scale om nonclinical ange a in ake o
nonclinical ange a e mina ion bu ea men conside ed as unsuccess ul o
unsa is ying–Case 5 (K izo e al.); Rebecca (De Sme e al.); J.J. ea ly ea -
men phase (Wa d & McLeod).
Type B: Change on sel - a ing scale om clinical ange a in ake o non-
clinical ange a e mina ion bu ea men conside ed as unsuccess ul o
unsa is ying–Paula, Jason, Sophia (De Sme e al.).
Type C: Change on sel - a ing scale om nonclinical ange a in ake o
clinical ange a e mina ion bu ea men conside ed as success ul o sa is y-
ing–Lisa, on one scale (Tho esen e al.); J.J., case s udy phase o ea men
(Wa d & McLeod).
The second main heme o his special issue is he concep o ‘illuso y
men al heal h’. The concep is, hough, used in di e en pape s in qui e
a ious deg ees. The concep was o iginally in oduced, de ined, and ope -
a ionalized in a pape by Shedle e al. (1993). Thei s udy design included
pa icipan s, ep esen ing a nonclinical popula ion, who comple ed he
Eysenck Neu o icism scale, a sel - epo ins umen hough o assess
6J. WAHLSTRÖM
a gene al psychological heal h-dis ess ac o , and he Ea ly Memo y Tes ,
a p ojec i e echnique aiming a p oducing a ich ma e ial o subjec i e
ela ional expe iences o be used as he basis o a clinical e alua ion o he
esponden ’s men al heal h o dis ess. A e his, he pa icipan s wen
h ough a labo a o y es in which hei ca dio ascula eac i i y was mea-
su ed du ing asks ep esen ing di e en le els o psychological s ess. Using
his design, he esea che s could iden i y a g oup o pa icipan s who ga e
sel - epo s o men al heal h bu we e clinically e alua ed as psychologically
dis essed, and who exhibi ed high ca dio ascula eac i i y in s ess ul
si ua ions. This g oup was in he pape e e ed o as ‘de ensi e denie s’ o
ha ing ‘illuso y men al heal h’. O he 41 pa icipan s who comple ed he
s udy, 18 we e classi ied in o his ca ego y. All in all, 29 ( ha is 71%!) o he
pa icipan s, ec ui ed among uni e si y s uden s and s a membe s, we e
clinically judged as ha ing psychological dis ess.
Theo e ically, he concep o illuso y men al heal h could be con-
nec ed o he di e en ypes o pa adoxical ou comes ou lined abo e.
In Type A, a clien would en e ea men o wha e e eason bu wi h
a de ensi e a i ude owa d mani es a ions o his o he psychological
dis ess, which would p e ail du ing and a e ea men . In Type B he
ea men would help he clien o cope wi h ‘su acing’ exp essions o
psychological dis ess bu he ‘ oo s’ o his o he p oblems would be
unsa is ac o ily wo ked on. In Type C, howe e , he clien would en e
ea men wi h a de ensi e a i ude bu as a esul o he p ocess would
become mo e open o his o he subjec i e expe iences, esul ing in an
inc ease in sel - a ed dis ess.
Two o he ou empi ical pape s in his special issue (Tho esen e al.,
2021; Wa d & McLeod, 2021) make mo e o less a icula e use o he
concep o illuso y men al heal h when analyzing hei cases and he
appea ance o pa adoxical o disc epan ou comes in hem. The pape by
K i zo e al. (2021) does no ac ually deal wi h he ques ion o pa a-
doxical ou come bu desc ibes he lack o ailu e epo s in published
psycho he apy case s udies–a wo hy opic indeed. The pape , hough,
does iden i y one clinical case s udy (Case 5) which could exempli y
a pa adoxical ou come o Type A, and pe haps he no ion o illuso y
men al heal h. The pape by De Sme e al. (2021), looking a ou cases
showing disc epancies be ween ou come sco es and clien s’ sa is ac ion
wi h he he apy, does no use he illuso y men al heal h concep a all
when accoun ing o he obse a ions.
Pa hways o pa adoxical ou come–a compa ison o cases
In he ollowing, I will make a compa ison be ween he epo ed cases wi hin
each o he h ee ypes o pa adoxical ou come I ou lined abo e.
EUROPEAN JOURNAL OF PSYCHOTHERAPY & COUNSELLING 7
esea ch in e es is in discu si e and na a i e p ocesses in psycho he apeu ic
encoun e s and hei ela ion o he ( e)cons i u ion o agency posi ions and sense
o agency as ou come o psycho he apy. On his and ela ed opics he has published
in se e al in e na ional jou nals and books.
ORCID
Ja l Wahls öm h p://o cid.o g/0000-0001-8191-8566
Re e ences
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e ec i eness? Psychology and Psycho he apy: Theo y, Resea ch and P ac ice, 85(1),
1–16. h ps://doi.o g/10.1111/j.2044-8341.2011.02019.x
De Sme , Von Below, Acke, We ba , Meganck, & Desme . (2021). When “good
ou come” does no co espond o “good he apy”: Re lec ions on disc epancies
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