The theoretical model and its applications
EPISTEMOLOGY AND THEORY OF THE BRIEF STRATEGIC THERAPY MODEL
The brief strategic approach to therapy is evidence-based (Szapocznik et al, 2008) and it is recognised as best practice in relation to some major psychopathologies. The model, formulated by Paul Watzlawick and developed by Giorgio Nardone (Brief strategic therapy, Giorgio Nardone’s Model), has been empirically and scientifically validated (Nardone, 2015; Pietrabissa, Gibson, 2015; Nardone, Salvini, 2014; Castelnuovo et al. 2011; Watzlawick, 2007) and it was registered as original invention at the World Intellectual Property Organization (WIPO) and it is a registered trademark.
The epistemology of reference is constructivist-interactionist. This was expressed in the collection of essays created by Paul Watzlawick in 1981, The invented reality, to which the most important authors of this perspective took part: Von Förster, Ernst Von Glasersfeld, Jhon Elster etc. This theoretical position distances itself from any form of determinism and reductionism, as well as from any strong theory carrying self-immune constructs (Popper 1972). Instead, it is based on the interactional-strategic paradigm of the Palo Alto School. This has led to choose “operational pragmatism” (Salvini, Nardone), where efficacy is the only form of truth. The theory itself is confirmed or disconfirmed by the application of its operational constructs.
Also, the research methodology is empirical, on the field, and not based on methods and criteria developed in aseptic laboratories. This methodology follows the Lewinian method of action-research that has been evolved and adapted to the clinical field. The other key element characterising our theory is, as explained more in detail below, the use of models of mathematical logic and linguistic predicates that go beyond the classical rational logic. In fact, the latter is not very apt to explain the phenomena of interaction between mind and mind, paradoxical and contradictory dynamics and the seemingly absurd beliefs that support psychopathological perceptions and reactions.
Since its assumptions, all of this makes the epistemological technique and the resulting operational constructs of our model of brief strategic psychotherapy completely original.
THE BRIEF STRATEGIC THERAPY MODEL
Since the first session with the patient, the model is oriented towards change. In fact, it does not use a classical procedure of diagnosis but rather an advanced technique of diagnosis-intervention: the strategic dialogue. This protocol, used for conducting the initial interview, allows the therapist to transform it into an action-research process, through a sequence of specific techniques (strategic questions, restructuring paraphrases, evocative formulas and final prescriptions), which leads patient and therapist to jointly discover “how” the problem works and “how” it can be solved.
On this basis, at the end of the first session, the therapist provides therapeutic prescriptions that fit the specific disorder of the patient.
In the following session, the effects produced by both the therapeutic dialogue and the prescriptions are evaluated.
If the outcome is positive, the therapist proceeds with the next steps of the model, otherwise what did not work is analysed and the target of the therapy is modified depending on the responses to the manoeuvres applied.
The focus of a brief strategic therapy is to restructure and change the patient’s rigid perceptions that induce their pathological reactions. To accomplish this, the intervention is aimed at interrupting the vicious circle created by the failed solution attempts implemented by the patient, which feed the disorder and its persistence supported precisely by those counterproductive reactions. Therefore, the dysfunctional “attempted solutions” need to be replaced with others able to disrupt the pathological balance and turn them into healthy and functional solutions.
Therapeutic strategies and stratagems are tailored on the problematic situation and on the specific form of expression of the disorder. As already mentioned, the number of therapeutic techniques, developed and formalised by Giorgio Nardone and his collaborators, is very copious. These cover the majority of forms of pathology that can be found in psychotherapy. Along with these strategies and stratagems, specific forms of therapeutic communication have been developed over the years. These are capable to circumvent resistance to change which is typical of any human system. In particular, it is worth mentioning “performative” communication, the language that makes the patient “feel”, in addition to understand and “injunctive” communication, which is the evocative language used to prescribe actions or thoughts to which the patient would usually object.
This is what Paul Watzlawick defined “hypnotherapy without trance”. If a therapeutic intervention produces the desired effects, we proceed to the consolidation phase of these effects through a process of redefinition of the changes made and of the resources and capabilities that the patient has shown to be able to use. The final goal is to guide patients to achieve complete autonomy and personal independence. For this purpose, each technique that was used is explained so that the former patient by this time can treasure it for their future.
METHODOLOGY OF THE AREZZO’S SCHOOL
Since the first research project on phobic-obsessive disorders in 1985, the main idea has been to develop general models of therapy towards specific protocols of interventions for specific disorders. These are fixed sequences of therapeutic manoeuvres with heuristic and predictive power, capable of guiding the therapist to break the specific pathological rigidity of the patient through particular therapeutic stratagems, and to restructure functional modes of perception and reaction to reality.
To realise this project, we did not only adopt the theoretical, applicative, and research tradition of the brief therapy developed by the Mental Research Institute in Palo Alto, which appeared as a rather rudimentary and unsophisticated criterion to develop an evolved model. Instead, we developed a new empirical and experimental action-research methodology in the clinical field, in line with the typical advanced research of physics and of the most evolved applied sciences. This is based on the assumption that “it is the solutions, and not the hypothetical explanations that lead to solutions, to explain the problems”.
Therefore, the model was built based on the following criteria:
- Efficacy: the ability of the intervention to achieve the targeted goals. In our case the elimination of the disorders presented by the patient;
- Efficiency: the ability to produce results in reasonably short time. In our case, a therapy should show results of improvements since the first sessions and it should lead to the solution of the problem within 3-6 months. In fact, as indicated by research literature, 50% of disorders can be solved within the first 10 sessions and 25% of disorders can be led to extinction with a therapy that does not exceed the duration of 25 sessions. Only the remaining 25% of cases requires longer treatments. (M.A. Hubble, B. L. Duncan, S. D. Miller, “” The Heart and Soul of Change “, American Psychological Association, Washington, 1999);
- Replicability: the quality of a therapeutic technique to be applicable to different people with the same type of disorder;
- Predictability: the effects of each therapeutic manoeuvre must be anticipated in such a way as to correct the unwanted effects during the therapeutic process.
- Transferability: the characteristic of a model that can be learned and applied by different people, that is, what makes a therapeutic technique a subject of psychotherapy training.
In addition, non-ordinary formulations were adopted from mathematical logic. These allow to use self-deception, beliefs, paradoxes and contradictions, as structural elements of rigorously constructed logical models (Newton Da Costa, Nardone).
In other words, with the contribution of formal logic, creative therapeutic stratagems, based on non-ordinary logic, could become formalised instruments within models of intervention proven effective and replicable.
All this led to protect, during the development of therapeutic strategies, both creativity and method. Such a work of empirical study aimed at the development of therapeutic sequences was applied to thousands of cases for over 25 years and it brought, as evidenced by the numerous publications (see bibliography) to the formulation of evolved protocols of brief therapy. These consist of innovative techniques that are specially-made to unlock specific types of persistence related to the most important mental and behavioural disorders.
These treatment protocols have been proven capable of solving some relevant forms of pathology, such as phobic-obsessive disorders, compulsive disorders and eating disorders with a higher rate of efficacy and efficiency than any other type of therapy, (Nardone-Watzlawick 1997, Nardone-Watzlawick 2005, Castelnuovo et. al 2011. Nardone, Ranieri Brook 2011, Nardone-Salvini 2013).
Finally, this industrious action-research in the clinical field led also to develop new assumptions concerning both the structure of problem solving processes and the characteristics of therapeutic communication, in their unfolding step by step from the beginning to the end of a therapy. Another fundamental characteristic of the brief strategic therapy model is the fact that, in line with strategic logic (a specialised branch of mathematical logic), therapeutic interventions are not built on the theory assumed in advance by the therapist but they are based on the objective to be achieved and the characteristics of the problem to be solved.
Therefore, the preliminary assumption of the model is the refusal of any normative-prescriptive theory, including systemic theory from which, in some respects, brief therapy is derived. In fact, it is believed that any a priori assumption works as an “implied” judgment (Salvini, 1991) or misleading prejudice to develop effective solutions. In contrast, tailoring an intervention to the prerogatives of the problem and to the objective to be achieved, leads to build a well-focused strategy that must be able to “self-correct” in its interaction with the problem. In other words, the strategy adapts itself, tactic after tactic, to the responses arising from the interventions that are put in place: as in chess, an opening move is followed by other moves that follow each other based on the opponent’s game.
If the opponent’s strategy, namely the mode of persistence of the disorder, is among those well known, a formalised sequence of checkmate in a few easy steps can be attempted, that is, a specific treatment protocol. In this case, the measurement of the effects will not only be between the start and end of the therapy, but it will be aimed at each stage of the therapeutic process, because, as in a strict mathematical model, all the possible responses to each manoeuvre are hypothesised and then verified through empirical and experimental practice. This approach leads to reduce the number of possible responses to a maximum of 2 or 3 for each intervention, allowing, in this way, the therapist to build the next move for each of those possible responses. Then, we proceed with a procedural measurement of the effects and of the predictive value of each manoeuvre and not only of the entire treatment process.
RIGOUR DOES NOT MEAN RIGIDITY
“Rigor alone leads to death due to asphyxia but creativity on its own is sheer folly“
Everything stated in the previous section applies to the study of the structure of interventions and their constitutive logic. However, different considerations need to be made about the adaptation of the intervention to every single person, family and socio-cultural context. In this respect, all the criteria of “control” and ” policy and “predictability” are not applicable. In fact, as already affirmed by Milton Erickson, each individual has unique and unrepeatable traits and their interaction with themselves, other people and the world is always something original.
Therefore, every human interaction, including the therapeutic one, is unique and unrepeatable. Within this interaction, it is up to therapists to adapt their own logic and their own language to the patient’s one. In this way, they can proceed with the investigation of the characteristics of the problem to be solved, until the disclosure of its specific persistence mode. Once the peculiarities of the persistence of the problem have been identified, the therapist will use the type of problem-solving logic that appears to be more appropriate. Its constitution and application will follow the model described above but every single manoeuvre will be formulated in such a way to adapt it to the logic and the language of the patient. In this way, the therapeutic intervention maintains its ability to adapt to the singularity of each person and situation and keeps, at the same time, its strategic rigour concerning the structure of the intervention.
To further clarify this essential concept, it is important to explain that what can be determined is the strategy in terms of structure of the intervention that can be adapted to the structure of the problem and its persistence; what changes is the therapeutic interaction, the relationship with the patient and the type of communication that is used. Therefore, even when a specific treatment protocol is adopted, as in the case of phobic-obsessive disorders and variations of eating disorders, each manoeuvre is always different but it always remains the same. In fact, the way it is communicated and adapted to the person changes, but the strategic manoeuvre remains the same at the level of problem solving procedure. As it is indicated by the ancient strategic wisdom: “change always to remain the same.”