Brief Strategic Therapy is the most innovative result of the meeting between the tradition of brief systemic-strategic therapy of the Mental Research Institute in Palo Alto, California and the technical solutions created by Milton Erikson in the context of the so-called hypnosis without trance.

The clinical research and practice carried out during the last fifteen years by the C.T.S. of Arezzo directed  by Prof Giorgio Nardone, has produced significant enhancement in the efficiency and effectiveness of therapeutic intervention.

During these years action research has been carried on more than 1,000 cases treated by the over 60 affiliated CTS clinics in Italy and other countries. The result of this massive research was the formulation of original protocols and advanced intervention models, for the treatment  of specific clinical problems, such as:

- Anxiety and phobic disorders

- Obsessive-Compulsive

- Dysmorphophobia

- Depression

- Eating Disorders
- Hypochondria
- Paranoia
- Eating disorders
- Family problems
- Marital/Couple conflicts

- Presumed Psychosis

- Relational problems and others

 

Anxiety and phobic disorders

Fear, panic and phobias are undoubtedly the topics to which we are mostly associated and attached to, given our long experience in this field of study. Our first work on obsessive-phobic disorders dates back to the late 1980s. The first published research dates back to 1988 (Weakland and Ray, 1995) and it showed that 19.2 percent of the resolved cases took place between the first and the tenth sessions, 61.5 percent were resolved between the tenth and the twentieth sessions, 3 percent were resolved between the twentieth and the thirtieth and 15.3 percent at the thirtieth and the thirty-fourth sessions.

During these last fifteen years, at CTS, we have treated thousands of patients with phobic and obsessive disorders, and this inestimable exposure permitted us to set up a series of specific strategies tailored to the particular type of persistence of each form of recurrent pathology. At present, the efficacy of the advanced treatment model for anxiety, phobia and panic attacks is equivalent to 95 percent (Nardone and Watzlawick, 2004), with a mean efficiency of seven sessions, during which the majority of the cases (81 percent) got unblocked within the fifth session and in 50 percent of these cases there were no traces of the relevant symptoms after the first session.

These include:

- Anxiety and Block of performance

- Panic attacks

- Panic attacks with agoraphobia

- Agoraphobia

- Social Phobia

- Other monophobias

Obsessive-compulsive disorders

Another major project carried out at the Centro di Terapia Strategica has been the study of obsessive-compulsive behavior syndrome. We have been studying this highly intimidating disorder and its treatment for more than fifteen years. During this long-term experience we have treated successfully more than two thousand patients with persistent and complicated obsessions and compulsive rituals. Based on the research-and-intervention method, this study turned out to be a surprisingly good instrument for acquiring operative knowledge about obsessive-compulsive disorders.

The typical perceptive-reactive system of obsessive-compulsive syndromes is maintained by the attempted solutions of avoidance and control of anxiety-laden situations through compulsive repairing or preventive rituals. Repairing rituals are carried out to intervene and repair after a feared event has taken place, so that the patient will not feel in danger, and so it is oriented toward the past. Preventive rituals are focused on anticipating the frightening situation to propitiate the beast or to avoid the worst outcome; therefore it is oriented toward the future.

During our long experience in trying to put together the best possible treatment for obsessive-compulsive disorders, we have devised many specific counter-rituals prescribed specifically to fit the different typologies of compulsive symptomatology. So we have now, at our disposal, a series of preset specific prescriptions that have proved to be effective with the different forms of obsessive-compulsive disorders.

Dysmorphophobia

A postmodern disorder that holds the same perceptive-reactive system as all the other phobic-obsessive disorders is dysmorphophobia, i.e. the obsessive fear of one’s physical appearance. This disorder is related to our always growing aesthetic sense and to the leaps of progress made by cosmetic surgery during recent decades, in connection with the postmodern notion that we have now advanced so much that we are able to change even the apparently immutable, such as our own physical, genetically determined appearance.

Until twenty years ago, those who longed to better their appearance to become more attractive had to appease themselves by going to the gym or using traditional aesthetic cures, but surely these natural means could not change their physical “flaws”. Nowadays this is possible thanks to cosmetic surgery. In our Westernized culture, both males and females undergo plastic surgery on various parts of their body, confident in bettering their appearances.

Cosmetic surgery is in itself a useful and precious science, but its excessive and improper use can render it decisively harmful and dangerous. Unfortunately, even in this case, what might be useful might become harmful if rigidly repeated. Therefore, when a person becomes obsessed about an aesthetic peculiarity that he refuses to accept, his attention is always focused on this “defect”. He lives with this torment throughout the day, which then turns into panic at the sight of a mirror or at an indiscreet glance. Thus the person finds a possible solution and, to try to overcome the problem, puts all his faith in cosmetic surgery.

However, it is necessary to point out that, in the majority of the cases, the aesthetic “defect” is either nonexistent or insignificant. The pathogenic idea of having an unacceptable aesthetic deformation is only a mental fixation, often related to relational problems with others and a profound sense of insecurity. The mind clings to an aesthetic defect to explain the foundations of these problems and holds the illusionary hope that, once this is removed or modified, everything will miraculously fall into place.

The danger is that this can give rise to a chain of never-resolutive corrective interventions, never resolute, that exacerbates the psychic pathology of the subject (Nardone, Portelli, 2005). In fact, the person, pleased with the achieved results, can always find something else in his body that can be bettered, thus the patient enters in a seemingly no-way-out trap: he takes up something that gives him the illusion of having control over his physical appearance, but, in reality, it makes him lose all control. One intervention will lead to another, then to another, and so forth. Think of the numerous Elvis Presley or Tom Cruise look-alikes who roam the globe, products of scalpels and extreme plastic-surgical interventions. Or think of the many people who start off with a simple nose job, then undergo breast enlargement, then decide on an eye-shaping intervention, and end up in a pervasive never-ending game. In such cases, the illusion of a surgical solution leads to more and more interventions, which in turn activate a sort of chain reaction that takes over entirely the subject’s thoughts, causing him or her to live in a constant need to sedate the reactions of panic triggered by the idea of having an aesthetic defect.

As in the case of obsessive-compulsive disorders, even in dysmorphophobia, the solution transforms itself into a new problem that requires a new solution, which in turn constructs another problem, and so on (Nardone, Portelli, 2005). This escalation often leads to real concrete tragic effects, e.g. real deformations, products of a series of aesthetic corrective interventions that might adjust a feature but decompose the overall harmony of the individual. The reader should not overlook the devastating effects of certain unsuccessful aesthetic intervention and of the additional attempts that render even more disastrous the preceding failures.

Another common attempted solution taken up by dysmorphophobics is isolation from social contact, so as to avoid the suffering and the panic crises triggered off by their constant feeling of being observed and judged. Afterwards, they desperately ask for relatives’ support for what seems to be for them, the only possible solution to their problem and their sufferings, i.e., plastic surgery. Even though the relatives understand clearly that the problem is psychological and not physical, they end up giving in to this request, because the suffering expressed by the subject seems devastating.

Generally, the dysmorphophobics refuse to undergo psychotherapy, because they are convinced they have a real aesthetic defect and not an erroneous pathogenic perception of themselves. All this makes it difficult to treat this severe pathology and often patients come to therapy only when the disaster has been accomplished.

When they eventually come to therapy, they should not be rationally persuaded into discontinuing this behavior. It will only increase their resistance to therapy. But they should be slowly made to see that what seems to have given them a means of controlling the problem eventually became a bigger problem, which they can no longer control.

Depression

In the last decade, depression has become a fashionable disorder, particularly due to the various debates regarding its biological and environmental causes. A great deal has been written about depression, but we would like to limit our explanations to the successful strategies in the treatment of this pathology.

From a strategic point of view, depression is regarded as the tendency to give up or renounce on life, due to a sense of helplessness given by a delusion (broken credence), regarding a rigid belief on oneself, others or the world.

The most common attempted solution expressed by depressed persons is complaint and self-victimization, which is often met by an encouraging, consoling, and protective attitude on the part of the subject’s family and friends. Therefore at the first stage of the therapy, cases of depression require a specific family-strategic type of intervention, followed by a reframing process of the individual’s perceptive-reactive system. We normally call in the whole family and invite them to be participants in the therapy, or, better still, we appoint them co-therapists. This is fundamental for the smooth running of the therapy.

Treatment is somewhat different for those depressive patients who come to therapy on their own behalf. There is a significant percentage of depressed patients who do not involve others in their miseries and try to struggle on their own to overcome this state of helplessness (Nardone, Portelli, 2005). In such cases we do not need to see the rest of the family but work individually with the patient. Nevertheless, once more our immediate intervention should aim to identify and consequentially block those failing attempted solutions carried out by the patient to overcome this state of depression, and at the same time pinpoint and reinforce functional strategies that can help rescue him or her from this seemingly close-ended labyrinth.

Eating Disorders

Eating disorders are in constant and rapid evolution, and thus need to be constantly studied in order to acquire effective and dissolving treatments.

Anorexia nervosa

Anorexia is undoubtedly the most studied eating disorder in scientific literature, given the alarming threat of starvation and death.  During these last ten years, at the CTS we have tried to avoid being trapped by the often intimidating nosographic description of this disorder, to focus on a more operative description, which could help us help patients find a way out from this seemingly closed labyrinth. Empirical-experimental research has lead us to understand that there are two distinct types of anorexia: abstinent and sacrificial (Nardone, Milanese, Verbitz, 2004).

Sacrificial Anorexia is the most well known type of anorexia. It has been very well described in the literature of the systemic tradition, particularly by the Milan school (Selvini Palazzoli, 1963). These young women typicall experience difficulties and developing symptoms in conjunction with particular family situations. In these cases, the family presents a “pathogenic” sort of energy, with one member usually assuming the whole weight of the problem by developing some psychological disorder, for example some form of delirium, psychosis or phobia – in other words, not necessarily an eating disorder.

Often these symptoms offer secondary advantages to the patient, rendering her the most important member in the family or in other social contexts such as school, work, group of friends etc. Secondary advantages can also provide a common enemy for the family to fight, thus avoiding to face other conflicting situations.

Clinical practice and literature clearly indicate that this variant is decreasing in comparison with abstinent anorexia.

In our works, abstinent anorexics are often metaphorically decribed as doning a medieval armor that protects them from their extreme sensitivity, but which entraps to eventually become their constraining prison. Abstinence becomes the attempted solution that seems impossible to give up, because, if they took off their armor, they would be unable to manage their emotions. Abstinent anorexics avoid eating as well as other enjoyable experiences, afraid of losing control. Weight loss becomes a means of anesthetizing emotions. Since abstinent anorexics cannot imagine any personal balance better than their own, they are extremely resistant to change (Nardone, Portelli, 2005).

Apart from individual solutions attempted by the abstinent anorexic, the solutions attempted by the system that surrounds her (particularly by her family) are also very important. Family members tend to make all kinds of efforts to help the subject by insisting that she eat, give her more attention, constantly checking on her, etc. Unfortunately, many of these attempted solutions complicate the problem instead of solving it. As Oscar Wilde declares  “All bad art is the result of good intentions “ and  often with all the good intentions we end up producing the worst consequences.

We normally administer a “mixed strategic and systemic” type of treatment for anorexia (Nardone, Milanese, Verbitz, 2004; Nardone, Portelli, 2005). We usually see the whole family in the first session and the young  woman alone at the following sessions woman . If this is not possible, we try to see the family at a later session—at least once in the course of the therapy. As mentioned, anorexia is a disorder that entangles other people, and there are always direct or indirect attempts by the family to make the patient eat. We therefore need to enlist family members as co-therapists. We use different prescriptions in the course of the therapy to guide them, with the goal of blocking all the usual attempted solutions (asking the person to eat, checking on her, etc.).

Sometimes, people suffering from anorexia, like those suffering from vomiting disorders, refuse to go into therapy. In such cases, it is often sufficient to see their parents and persuade them to stop all their attempted solutions. Most often, after a few sessions with just the family, most young women decide to come into therapy personally because they are irked by the changes in their parents’ behavior.

Vomiting syndrome/bulimia nervosa

Eating disorders are rapidly evolving toward a kind of “refined” specialization (Nardone, Milanese, Verbitz, 2004; Nardone, Portelli, 2005).  Our clinical research has lead us to denote that often young women with bulimic or anorexic tendencies eventually discover that vomiting enables them to control their weight without having to give up the pleasure of eating. Also, by staying just a few kilos above or below their ideal weight, they avoid alarming their families and being pressured to eat normally. Thus, in recent years, we have observed a considerable increase in cases of vomiting syndrome compared with the more “traditional” disorders of anorexia and bulimia.

Although the literature of our field (APA, 1994) still classifies the vomiting disorder as a variant of anorexia and bulimia nervosa, our empirical research has shown that the vomiting disorder is based on a completely different structure and model of perception of reality. Although bulimia (bingeing and gaining weight) and anorexia (abstaining from food in order to lose weight) form the basic matrix of vomiting disorder, the latter, once established, loses all connections with the disorder that initially produced it. In that sense, vomiting disorder is an example of an emerging quality, just as water is an example of an emerging quality of hydrogen and oxygen. Although hydrogen and oxygen are the elements that constitute water, they lose their individual characteristics, since water is something different and more than the sum of its elements.

Undoubtedly, when these persons initially start to binge and vomit, the vomiting represents an attempted solution, a way to lose weight, or avoid gaining weight, while continuing to eat. In other words, it is a way for the person to keep eating without feeling the harmful effects of her relationship with food. Initially, this is an attempted solution that works, but, when the cycle of eating and vomiting is continuously repeated, it becomes an increasingly enjoyable ritual; after a few months, it will have become the young woman’s greatest pleasure, and one that she can no longer do without.

Therefore, once the vomiting syndrome has become established, the problem is no longer one of weight control, but one of controlling the compulsion toward pleasure. Eating and vomiting, which started out as an attempted solution with respect to anorexia and bulimia, becomes the problem, and the reason it persists lies in the pleasure that it provides. One of the findings of our research is that the obsessive search for pleasure and strong sensations is a prevalent characteristic of these subjects’ perceptive-reactive system.

Vomiting syndrome is a compulsion based on pleasure rather than a disorder based on suffering (as it was often consider and treated). This misconcept is what rendered this disoder so intimidating to treat and resistant to change. This revolutionary discover has offered brief strategic therapy important operative information to design  adequate instruments that follow the same logic of this disoder, leading to a more effective and efficient treatment.