Therapy as research, research as therapy

Since 1985, through an empirical experimental method, the Strategic Therapy Center of Arezzo has conducted research for the development of advanced models of solution-oriented strategic brief therapy.

The most interesting result was the formulation of protocols for the treatment of specific mental disorders - especially phobic-obsessive disorders and eating disorders (Nardone, Watzlawick, 1993; Nardone, Verbitz, Milanese, 1999) - with highly effective and efficient results, scientifically recognized as the most relevant in the psychotherapeutic field (87% of cases resolved with an average duration of seven sessions).

The central idea was to develop, starting from general therapy models, specific treatment protocols for particular pathologies, i.e. rigorous sequences of therapeutic maneuvers with heuristic and predictive power, capable of guiding the therapist by resorting to the use of particular stratagems therapeutic, to break the specific pathological rigidity of the disorder or problem presented.

Following this first significant change, the protocols were designed to guide patients to reorganize their perceptual-reactive system towards a more functional balance. The aim of this long and laborious research, applied to hundreds of cases over a period of over ten years, was to identify the most appropriate ways to solve each of the specific problems studied.

All this has also led to new assumptions about the structure and procedures of problem solving and the techniques related to the therapeutic relationship and language. These protocols were developed including specific techniques on the strategy, language and therapeutic relationship for each disorder or problem studied.

These protocols are strict but not rigid, since they are adaptable to the responses or effects obtained with the interventions introduced - just like in a game of chess where, after the opening move, the next moves depend on the opponent's play.

In a game of chess, if the player can find moves that reveal the opponent's strategy, then he is in a position to attempt a formalized sequence that will lead to checkmate.

The same happens in therapy: if an intervention manages to reveal the modality or persistence of a specific disorder, the therapist can develop a specific treatment protocol that will ultimately lead to the solution of the problem presented.

In brief strategic psychotherapy, the evaluation of the outcome is not formulated at the end of the therapy, but at each stage of the therapeutic process. As in mathematics, we look for all possible answers to each maneuver, and then verify them through empirical experimental procedures. This methodology allows us to restrict the possible answers (to a maximum of two or three for each intervention), allowing us to prepare the next move for each possible answer.

So we proceed by obtaining an evaluation of the effects and the predictive power for each single maneuver, and not only for the overall therapeutic process.

The systematic research process applied in various forms of psychological disorders has proved to be an important research tool. In fact, the data collected during our research allowed us to develop an epistemological and operational model of the formation and persistence of the pathologies under study. This has led us to a further improvement of the solution strategies, in a sort of spiral evolution fueled by the interaction between empirical interventions and epistemological reflections, leading to the construction of specific and innovative strategies (Nardone, Watzlawick, 2004).

Research applied to our clinical work (Nardone, Watzlawick, 2000; Nardone, 1993, 1995a; Nardone, Milanese, Verbitz, 1999) has allowed us to identify a series of specific models of rigid interaction between the subject and reality. These models have led to the onset of specific types of psychological disorders, which are maintained by the repetition of attempted dysfunctional solutions.

This leads to the formation of what we call Pathogenic "system of perceptions and reactions"[1], that is, a stubborn persistence in resorting to strategies that are supposed to be effective and that have worked for similar problems in the past, but which now only maintain the problem (Nardone, Watzlawick.

Thus the evolved model of the strategic approach goes beyond the nosographic classifications of psychiatry and clinical psychology by adopting a problem classification model in which the "perceptive-reactive system" construct replaces the traditional categories of mental pathology.

All this goes against the current tendencies of many therapists who initially rejected the traditional nosographic classifications, but who today seem to want to recover their use. From our point of view, classification is just another attempt to force facts and frame patients in their own theory of reference, without any concrete operational value.

In the light of these epistemological assumptions, it seems essential to us to formulate what we call "operational" diagnosis (or "diagnosis-intervention") in the definition of a problem, rather than a merely "descriptive" diagnosis. Descriptive perspectives such as those in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and most of the diagnostic manuals propose a static concept of the problem, a sort of "photograph" that lists all the essential characteristics of a disorder. On the other hand, this classification does not provide any operational indication as to how the problem works or its solution.

By operational description we mean a type of cybernetic-constructivist description of the persistence modality of the problem, i.e. how the problem feeds itself through a complex network of perceptive and reactive feedbacks between the subject and personal and interpersonal reality (Nardone, Watzlawick, 1990).

Based on these premises, in our opinion the only way to know a reality is to intervene on it, since the only epistemological variable we can control is our strategy, that is, our "attempted solutions". If and when a strategy works, it allows us to understand how the problem has persisted. We come to understand a problem by introducing a change: as the title of this book suggests, change in order to know.

This is consistent with Lewin's (1951) notions of stasis and change. Lewin argued that to understand how a process works it is necessary to produce a change, observing its effects and new dynamics. On the basis of this assumption, we come to understand a reality by working on it, gradually adapting our interventions and adapting them to the new elements that emerge.

The advanced therapy model is the final result of this experimental empirical process, resorting to models of mathematical logic, which can be continuously checked and verified, and which, thanks to its formalization, is also replicated and taught.

Finally, such a model is not only highly effective and efficient, but also predictive.

This last characteristic has allowed us to transform an "artistic" practice into an advanced technology, without losing the creative aspect, necessary for its continuous innovation process. All this takes place with the utmost respect for scientific rigor.

Obviously, any intervention must take into account the individual patient, for whom it should be tailor-made.

As Erickson argued, each individual has unique and unrepeatable characteristics, including interactions with himself, others and the world. Therefore each case always represents something original. Consequently, every human interaction, including the therapeutic one, is unique and unrepeatable, and the therapist must adapt his own logic and language to those of the patient.

Only if the therapist is able to understand the underlying logic and use the "patient's language" can he proceed to investigate thoroughly and "successfully" the problem presented and its specific modes of persistence. Once the ways of persisting the problem have been clarified, the therapist will be in a position to use the problem solving logic that seems most appropriate.

The therapist can now work out each maneuver, adapting it to the patient's logic and language. So, the therapeutic intervention can maintain its ability to adapt to the peculiarities and situation of each patient, without however losing sight of the structural rigor of the intervention.

The strategy is adapted and shaped on the structure of the problem and its persistence, while the therapeutic relationship and the language used must be tailored to each patient.

Therefore, even when we adopt a specific treatment protocol, such as for phobic-obsessive disorders or those of nutrition, each maneuver is different while remaining the same, since each intervention undergoes changes in its communicative and relational aspects, while maintaining the same strategic problem solving procedure. In this sense we aim for rigor and not rigidity.

George Nardone
(co-founder and director of the Strategic Therapy Center)
based on the book Change to know

[1] By perceptive-reactive system we mean the redundant modalities of perception and reaction of the individual towards reality. These modalities are expressed in the functioning of the three fundamental and independent types of relationship: between Self and Self, Self and others, and between Self and the world (Nardone.