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Fresh from graduation, on the first day of internship at a facility for the so-called "psychiatric patients", I hear thunder from the specialist on duty: "For you, psychotherapy does not exist!" In the naive enthusiasm of inexperience, I was shocked by this assertion. Then, studying and gaining experience, I understood the meaning of that sentence and that the majority of my colleagues are much more in line with the distinguished specialist, than with us strategists, considered not by chance for years the heretics of psychotherapy. Enrico, as I like to call him, was a 45-year-old man with obsessive compulsive personality disorder, associated with the persecutory paranoia of being poisoned by loved ones, in a sort of conspiracy.
Enrico suffered from this disorder since adolescence and, in this state, not only had he isolated himself from the world, but, for years, had undergone complicated washing and disinfection rituals, to the point that the skin, by dint of rubbing it , it had thinned so much that it tore apart just looking at it. When the father dies, the mother, no longer managing the situation, turns to the public service which finds the structure of my internship for Enrico, where the only cure, besides antipsychotics, is the locking of the bathrooms.
Over and over, I wondered why no one did anything for that man who was imprisoned by his own unfortunate diagnosis. Then, passing the time and observing the situation from the inside, I realized that something could be done for him, but, simply, no one knew what. What I mean is that, although the diagnosis was certain and from a descriptive point of view there was no doubt about it, what prevented the treatment was the fact that the descriptive diagnosis tells us what ailment it is, but not how it works and , above all, how to go about solving it.
Some time has passed since then, I have seen so many men like Enrico go through the Strategic Therapy Center of Arezzo, where, having the good fortune to work alongside Giorgio Nardone for 15 years, I was able to notice the evolutions of the technique, of the protocols, of the way of doing therapy from a not only technical point of view, but also of communication and relationship . I was able to take part in several important projects, which have marked the history of Brief Strategic Therapy, right up to the end, which led to the drafting of the text "Long-term short-term psychotherapy”, On which I feel I can spend a few words, to share with the reader the meaning of our work, even in a field as thorny as that of personality disorders.
Thanks to three decades of research-intervention, implemented by applying solution stratagems that follow the principles of science (effectiveness, efficiency, replicability, generalizability and predictivity), we have come to the formulation of a therapeutic process that, respecting the aforementioned criteria, could also respond to the needs of people defined as chronic, rather than borderline, psychotic or, again, incurable.
Going in order, we started with intervention protocols for disorders with clear and obvious symptoms, such as panic attacks, phobias, obsessions and compulsions, eating disorders and sexual dysfunctions. In the majority of these clinical areas, the disorder coincides with the symptomatology, once extinguished, which the subject recovers his psychological balance (Nardone, Watzlawick, 2005). Afterwards, we have increasingly come across ailments that have persisted for years, therefore chronic, for which it emerged the need to add to the first "strategic" part a subsequent phase of supervised reorganization of the patients' lives, so that, freed from the disabling symptoms, in addition to stabilizing the results, they could build a new balance , which spontaneously would not have come about.
We have therefore abandoned the therapeutic techniques of the systemic tradition (Bateson, Weakland, Haley, 1956) which we used in the early days with the major psychopathologies, further perfecting the techniques and therapeutic models already formalized, so that they fit the phobic variants of these pathologies, as well as for the different forms of obsessive-compulsive disorder, eating disorders and sexual dysfunctions. This technological evolution has made the model even more rigorous, systematic, and at the same time flexible and adaptable to the specific therapeutic needs of the numerous symptomatic variants of the disorders.
As psychosis or presumed such we have classified the series that highlighted disorders with blatant delusions, delusions of persecution, hallucinations and marked dissociative states, combined with the inability to build and maintain meaningful relationships, or the presence of pathological complementarities of addiction, or even cases in which the different acute symptoms alternated with each other. These are pathologies with little regularity and many exceptions to the rule, with which, rather than formulating a replicable and predictive therapeutic protocol, the definition of single techniques and therapeutic maneuvers capable of undermining the pathological rigidity and eliminating, is much more strategic. or to significantly reduce the degree of invalidation caused by the symptomatic expressions of the disorder.
As expressed elsewhere (Nardone, Watzlawick, 1990; Nardone, Balbi, 2008), an effectively effective therapeutic change must have the extinction of the disorder and its symptomatic expressions as the first therapeutic goal, using techniques that circumvent resistance to change, to get results quickly. This should be followed by the construction of a psychic and behavioral balance that allows to avoid relapses in the disorder and to express the full potential of the individual, through a learning process by means of experiences and acquisitions.
In other words, the first part of the therapy is purely strategic, the second experiential evolutionary, in order to consolidate the therapeutic changes and develop trust in personal resources, thanks to a restructuring of the perceptual-emotional modalities. The third phase is cognitive and aims to arouse self-esteem and a sense of self-efficacy; the therapist becomes a supervisor or consultant who supports the subject in critical moments, but never replaces him.
He does not "prescribe", but takes a position that pushes the subject, through orienting questions and paraphrases that redefine the different perspectives of problem analysis, to discover his own personal resources for the acquisition of security and autonomy. The therapeutic path ends when the patient declares to feel safe and autonomous, no longer at risk or in the balance, therefore able to face the problems posed by life.
The persistence of the disorder over time does not lead to the prolongation of the therapeutic phase of our work, but rather implies the need for a type of long-term therapy, only as a continuation of a previous therapy that gave therapeutic results in the short term. (Watzlawick, 1974; Nardone, Watzlawick, 1990-2005; Nardone, Portelli, 2016; Nardone, Balbi, 2015). In terms of methodological evaluation, efficiency confirms effectiveness, just as the technique must be replicable in order to be rigorous, or give more or less the same results applied to the same types of problems.
To prove even more advanced and technological, it must predict the outcomes of each single therapeutic maneuver within the entire therapeutic strategy in its sequentiality, that is, be predictive. In the words of Paul Watzlawick, who are "the fact that a pathology has suffered for many years does not mean that its therapy must be as prolonged and painful».
Coming to the therapeutic outcomes, we examined three clinical areas requiring short-term psychotherapy in the last five years, about 35% of the subjects treated at our Center and those affiliated: chronic cases, borderline disorders and psychotic spectrum disorders. Of the chronic patients, 88% completely solved the problem, while in terms of efficiency the number of sessions was between 12 and 20 in the space of a year. In borderline disorders, 71% had a positive outcome, with treatment prolonged for approximately three years and a number ranging from 15 to 35 sessions. With regard to the psychotic spectrum, the effectiveness is 59% of cases, with a number of encounters between 10 and 39.
In more than 80% of the cases of the entire series, the disabling symptomatology was eliminated or significantly reduced within the first 5 meetings. Certainly we still have a lot of work to do to raise the possibilities of treatment, but we are confident in the possibility of further evolving in this direction (Nardone, Balbi, Bartoletti, Vallarino, 2017).
Even the most imposing palace, in our experience, if mined in the right places, can collapse quickly, while its construction requires a long and tiring job, as happened for Giona, Cati, Serena, Erika, Anna, Giacomo, the protagonists of the our book, and for all those we meet daily in our clinical practice, who, like tightrope walkers, learn to walk on the tightrope, each becoming his own stabilizer bar for himself, while we continue to look at them, gradually more and more from far away, and always ready to intervene should they ever need us again.
Dr. Elisa Balbi (Psychotherapist, teacher and official supervisor of the Strategic Therapy Center)