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 about illnesses or contamination of various kinds, he assumed was his own, which plunged him into a state of anguished panic. The person had come to me after years of treatment with drugs, psychoanalysis, and after attempting magical means through sorcerers, psychics, and some clerics.

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 him again after a week and found him completely changed . Smiling and serene, he told me he hadn't had those major problems for a few days and felt more eager than ever to rebuild a new life based on his new state of health and psychological strength. More surprised than he was by this change, I tried to understand how it could have happened and 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.

Having discarded all previously attempted strategies (drug poisoning, trying to get into a car accident), he decided, perhaps because the railroad tracks were near his house, to throw himself under the train. Thus, according to his own words, as the sun was about to disappear over the horizon, he lay down on the railroad tracks, thinking of all the bad things in the world, waiting for the "liberating" passage of the train. But, strangely, at that moment he saw only 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; so much so that he entered a state of profound relaxation and abandoned himself to 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 recalled Erickson's lectures, which I had read some time ago and which were then considered accounts of "shamanism" and certainly not rigorous therapies. The idea that formed and took hold in my mind was that it would be fantastic to be able to deliberately induce, through systematically constructed interventions, sudden changes like the one that had occurred by chance . In practice, I began to think that what I would really like to do was study the possibility of intervening in so-called psychopathologies in such a way as to magically bring about 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 amusing and coincidental episode occurred around that time. One day in July, a woman suffering from panic disorder and agoraphobia was in my office . For several years, she had been unable to leave the house without being accompanied, just as she could not stay home alone without panicking. Since it was very hot, I got up and went to the window to open it; as I moved the curtain, the pole it was hanging from slipped out of its socket and fell violently on my head, hitting me with its sharp end. I initially played down the episode by making a few jokes about the grotesque phenomenon, and then sat down again to continue the conversation with the woman, who, however, I saw blanch; at that point, I began to clearly feel the blood dripping from my head.

I stood up, still trying to reassure her with a few jokes, went to the restroom to look at myself in the mirror, and realized the seriousness of the wound. So I returned to the office and told her I needed to be taken to the emergency room for the necessary dressings. The patient readily offered and, forgetting that she hadn't driven in years due to her phobia, drove my car to the city hospital, where, once again forgetting her fear, she undauntedly watched the entire medical procedure, including disinfection and stitches, playing a protective and de-escalatory role over me . We then returned to the office where the husband, who had meanwhile arrived to pick up his wife, watched, astonished, as she calmly returned to the wheel of 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 point on, my studies and clinical applications focused on experimental research and the development of these types of "strategic" interventions: that is, brief forms of treatment built on established objectives, capable of leading subjects to change almost without realizing they are changing . But to do this required a decisive emancipation from traditional conceptions of psychotherapy and drawing on studies on change, interaction, and human communication. This study and research brought me into direct contact, as an "apprentice," with the MRI group in Palo Alto, particularly with Paul Watzlawick, who showed me, in the light of both concrete clinical experiences and innovative forms of epistemology, the possibility of constructing, in 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, I equipped my office in the classic manner of Bateson's systemic researchers: with a closed-circuit television camera and an observation room. I began videotaping the encounters with phobic patients to whom I applied the MRI brief therapy model with some initial personal modifications and adaptations. Afterwards, I re-observed the therapeutic interaction as it unfolded and its effects, paying particular attention to the maneuvers and communication used. In this way, I began to correct maneuvers that were found to be ineffective or misleading and to repeat what appeared capable of influencing the 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 final outcome could be described as something similar to checkmate in a few moves in chess. However, unlike chess, it soon became clear that in therapy, the quality of interpersonal relationships between therapist and patient(s) was a crucial factor in 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, we can consider the goal of developing a systematic, rigorous intervention model that deliberately, and with less risk, produces what had happened by chance in the two cases initially reported, to have been achieved . That is, to construct an "invented reality" within the therapeutic interaction capable of producing concrete effects in the patients' daily lives.

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)