Brief Strategic Psychotherapy: A brief history of the research-intervention

 

True truths are those that can be invented

Karl Kraus

 

 

In 1983, on a usual working day, a gentleman from a town near Arezzo came to me, presenting a desperate picture of fears and obsessions that had haunted him for years. He transformed every slightest alteration of bodily sensations as the clear sign of having contracted who knows what "dark evil". He did not leave the house unless accompanied for fear of feeling bad.

Whatever he read or heard on TV, relating to illnesses or contaminations of various kinds, was assumed by him as his own, which plunged him into an agonizing situation of panic. The person came to me after being treated for years with drug therapies, psychoanalysis and after trying magical ways through sorcerers, seers and some religious.

I asked the person why, after trying so many treatments, he had turned to me, so young and inexperienced and I stated that I could do very little for him as the problem was very complicated and given my lack of experience. Our first interview, in which he told me all his misfortunes and I repeatedly declared his low probability of recovery and above all my complete disillusionment with what I could have done for his case, took place entirely in an atmosphere of pessimism and discouragement.

I saw the person again after a week and found myself in front of a completely changed person. Smiling and serene, he declared to me that he had not had those big problems for a few days and that he felt more eager than ever to rebuild a new life on the basis of his new state of health and psychological charge. Surprised more than him by this change, I tried to understand how this could have happened and I asked him to tell me what had happened to him during the week.

After leaving my office, the patient felt deeply depressed, discouraged and with the desire to get it over with, moreover, in the past, he had attempted suicide several times. In the following days, these thoughts of suicide had progressively increased. He reported that, for two or three days, he had been thinking about what his life would be like with no hope of recovery from his ailments and that in the wake of such desperation he had been actively thinking about how to get himself out.

Discarding all the strategies he had already tried (drug poisoning, looking for a car accident) he thought, perhaps because there was a railway near his house, to throw himself under the train. So, according to his exact words, when the sun was about to disappear on the horizon, he lay down on the railroad tracks, thinking about all the bad things in the world, waiting for the "liberating" passage of the train. But, strangely, at that moment he only saw the possible good things in existence. In short, while he was there waiting for the train, he began to have a positive idea of ​​existence; to the point that he entered a form of deep relaxation and indulged in all these mental images relating to a possible happy existence, free from the terrible symptoms.

Suddenly the sound of the oncoming train awakened him from that pleasant state. For a moment he was almost surprised to be there and, with a flicker, jumped off the rails before the train reached him. He was back to reality. He realized that he was there waiting to commit suicide and as if by magic he was now seeing things in a new way, he felt like another person who no longer had any intention of dying. Since then the fears in his mind disappeared as if by magic, and he began to go out looking for old friends abandoned by the isolation due to his illness. He no longer felt those frightening symptoms on him. He had a great desire to live and also began to look for a job, an activity that he had always abandoned due to his ailments.

I continued to see the person for a few months, witnessing his gradual progressive evolution towards a life free from the fears and obsessions of the time regarding therapy, as it seemed unthinkable, in the light of the traditional concepts of psychotherapy, that a so sudden and rapid recovery. This experience functioned in men as a kind of "enlightenment".

I was reminded of Erickson's readings, made some time ago and then considered reports of "shamanic" and certainly not rigorous therapies. The idea that formed and took hold in my mind was that it would have been fantastic to be able to deliberately provoke, through systematically constructed interventions, sudden changes such as that which happened by chance. In practice, I began to think that what I really would have liked to do was study the possibility of intervening in the so-called psychopathologies in such a way as to cause, as if by magic, rapid and effective changes.

With these ideas in mind, I went to carefully reread Erickson's works and found that his methods, which could appear, at first suspicious reading, as something not very systematic, instead possessed refined strategic constructions and decidedly systematic tactical structures. I found such strategic refinement and tactical systematicity, even more rigorously studied, in the light of modern epistemology and research in the human sciences, in the publications of Watzlawick, Weakland and their colleagues from the Palo Alto school.

In short, thanks to that casual and surprising case of sudden recovery, my conceptions opened elastically to innovative perspectives regarding the formation of human problems and their solution. The thing that then became clear to me, studying well the works of the Palo Alto group, was a possible concordance between the epistemological studies of the natural sciences and those of the psychological and social sciences, something that until then had appeared absolutely unsustainable in the light of comparisons. between the research methods of the physical and natural sciences and those of traditional psychotherapeutic concepts.

Another nice and casual episode happened just in that period. One day in July, in my study, there was one lady suffering from panic disorders and agoraphobia. For some years she had not been able to leave home, if unaccompanied, just as she could not be alone in the house without being panicked. As it was very hot, I got up and went to the window to open it; as she moved the curtain, the pole from which it was hanging, she slipped from her seat and she fell violently on my head, hitting me with the sharp end of her. At first I played down the episode by making a few jokes about the grotesque phenomenon and I sat down again continuing the conversation with the lady, who, however, I saw whiten; at that point I began to clearly feel the blood dripping from her head.

I got up, always trying to calm her down with a few jokes, went to the toilet to look at myself in the mirror, and realized the seriousness of the wound. So I went back to the office and told her that I had to be accompanied to the emergency room for the necessary medications. The patient promptly offered herself and, forgetting that she had not driven for years due to her phobia, drove my car to the city hospital, where, once again forgetting her fear, she watched undeterred throughout the medical procedure, including disinfections and the suturing of the stitches, playing a protective and defusing role towards me. We then went back to the studio where the husband had arrived in the meantime to get his wife back, he saw her, astonished, quietly go back to driving the car.

However, he was even more surprised by his wife's behavior in the previous episode, which, in the light of the "historical" problems of fear, appeared not only surprising, but almost miraculous. But the surprises for her husband did not end there. In fact, in the days following this episode, the lady began to go out alone, driving the car quietly, and gradually resuming to carry out many activities hitherto abandoned due to her fear. Only a few more sessions of gradual and progressive guidance were needed for the exploration and exposure to situations that had hitherto been considered frightening, to lead the lady to a complete overcoming of the phobic symptoms.

As the reader can well understand, even this fortuitous and curious episode made me reflect a lot and led me to think about how beautiful it would have been to be able, through deliberately imposed prescriptions to patients, to produce concrete experiences similar to this one. Events capable of making people experience alternative modes of perception and reaction to reality and, therefore, capable of gently leading them to overcome fear.

From that moment on, my studies and my applications in the clinical field focused on the experimental study and on the development of these types of "strategic" intervention: that is, short forms of treatment built on the basis of the intended objectives, capable of conducting subjects to change almost without realizing they are changing. But, to do this, a decisive emancipation from the traditional conceptions of psychotherapy was needed and to draw on studies related to human change, interaction and communication. This study and research led me to direct contact, as an "apprentice", with the MRI group of Palo Alto, in particular with Paul Watzlawick who showed me, in the light of both concrete clinical experiences and innovative forms of epistemology, possibility of building, in the interaction between people, "invented realities" capable of producing concrete effects.

Waztlawick and Weakland were the precious supervisors, rigorous and at the same time encouraging, of the study project and development of a specific brief therapy protocol for phobic-obsessive disorders.

Thus the study and clinical research work on severe forms of fear, panic and phobia began to take concrete shape. The choice to deal specifically with these clinical problems was due to some factors: a. my dissatisfaction with the results obtained with traditional forms of psychotherapy; b. the fact that a conspicuous amount of phobic cases presented itself to me at that time, coincidentally after the two curious cases reported, which despite my declared absolute non-responsibility and merit of their changes, made me a great publicity; c. the "Brief Thrapy" model of the RIM, applied to the most disparate human problems, as a result of its tradition of systemic and family studies, appeared to be little applied to these specific problems.

Similarly, the other models of short systemic therapy presented themselves as not too specific for phobic disorders, while, on the contrary, in Erickson's works there were many examples of brief and strategic intervention on severe forms of phobias and obsessions. This direction of research, therefore, seemed to possess, in addition to the charm of being able to become "powerful healers" of serious forms of psychological symptoms, also aspects of novelty and originality that increased my enthusiasm.

First of all, I equipped my studio in the classic Bateson systemic research way: with a CCTV camera and observation room. I began videotaping the encounters with phobic patients to whom I applied the brief therapy model of MRI with some personal modification and initial adaptation. After that, I re-observed the therapeutic interaction in its development and in its effects, with particular attention to the maneuvers and communication used. Thereby, I began to correct the maneuvers found to be ineffective and misleading and to repeat what appeared to be capable of affecting patients' change.

This experimentation has represented the leitmotif of my research-intervention work on phobic disorders. Indeed, it was precisely the success or failure in bringing about changes, and the consequent readjustments, that led to the evidence of the "how" certain dysfunctional human systems functioned in their problematic persistence, and the "how" it might be possible to solve, effectively and efficiently, such problems.

The first three years of work were a continuous experimentation of techniques, borrowed from many therapeutic agents, or invented from scratch, which could be useful. Each therapeutic maneuver, in addition to being studied, was analyzed in its most effective articulation and communication modality.

The usefulness soon emerged, not only of specific "procedures" for specific problems to be faced during the course of therapy, but also of a specific "process" of the treatment that would enhance the intervention power of the maneuvers and lead more effectively to the achievement of the set objectives.

After these three years of work, I came to the development of a first version of a specific short therapy model for phobic and obsessive disorders, consisting of a series of specific therapeutic procedures and a specific process. In analogy with the game of chess, the therapy process was divided into successive stages and phases.

Each phase was represented by specific objectives to be achieved; for these specific tactics and an equally specific modality of therapeutic communication were studied and developed. In this regard, a series of possible maneuvers were also studied to circumvent some foreseeable resistances put in place by the patient.

By experimenting with these first two forms of strategic protocols, we have come to the development of an intervention model consisting of a predetermined series of procedures, but at the same time endowed with elasticity and tactical adaptability to the foreseeable evolutions of the therapeutic interaction. Still in line with what the expert chess player does, who, in order to reach checkmate as soon as possible, plans certain moves trying to predict the opponent's counter moves.

As you can well understand, a patient and laborious empirical and experimental study of the usual reaction of phobic subjects was required to develop such a treatment protocol, which proved to be not only effective in the subsequent application, but also predictive and heuristic. to certain maneuvers. As well as the construction, sometimes of specific techniques that would allow to obtain the pre-established objectives, stage after stage of the therapy.

The end result could be described as something similar to what in the game of chess is checkmate in a few moves. However, compared to the game of chess, it soon became clear that in therapy the quality of interpersonal relationships between therapist-patient (s) was a crucial factor for the final outcome.

In this regard, Erickson's teachings on the use of suggestion within therapeutic communication, and Watzlawick's on the use of paradox, "double bonds" and other pragmatic communication techniques, have been an indispensable element for the development of strategic plans and specific therapeutic techniques.

To date, the objective of setting up a rigorous systematic model of intervention can be considered to have been achieved which would deliberately produce, and with less risk, what had happened by chance in the two cases initially reported.. That is, to build in the therapeutic interaction an "invented reality" capable of producing concrete effects in the daily reality of patients.

The therapist who performs these types of interventions is, in fact, like the wandering sage of the following Islamic story: «Alì Babà, on his death, left his four children 39 camels as an inheritance. The will provided that this inheritance was divided in the following way: to the eldest son should go half, to the second a quarter, to the third an eighth, to the youngest a tenth of the camels. The four brothers were arguing heatedly, as they could not agree. A wandering sage passed by, who, attracted by the dispute, intervened by solving the problem of brothers in an almost magical way. The latter added his camel to the 39 of the inheritance and began to make the divisions under the astonished gaze of the brothers: he assigned 20 camels to the elder, he gave 10 to the second, 5 to the third and the youngest 4. After which he got on the camel remaining, considering that it was his, and he left again for his wandering ».

In the solution of the brothers' dilemma, the wandering sage added one thing, indispensable for the solution, which he then recovered. Because once the problem was solved, this was no longer needed. In the same way, something is added to phobic patients, thanks to the therapeutic interaction, which is indispensable for the effective and rapid solution of the problem but then this thing is resumed, after overcoming the disorder, as this thing is no longer needed.

This type of intervention is only apparently "magical" as it is the result of an application of highly rigorous principles of persistence and problem solving. Principles which, in their application, provide for a creative adaptation to circumstances so that they are able to break the "spells" represented by complicated and self-reverberating human problems. After all, as Bateson stated, "rigor alone is death by paralysis, but imagination alone is madness".

George Nardone
(co-founder and director of the Strategic Therapy Center)
based on the book Fear, panic, phobias (1993)