DIALECTICAL INTERVENTIONS AND THE STRUCTURE OF STRATEGY
作者: HAIM OMER / 5026次阅读 时间: 2013年12月06日
来源: Psychotherapy 28
www.psychspace.com心理学空间网

DIALECTICAL INTERVENTIONS AND THE STRUCTURE OF STRATEGY

HAIM OMER

Tel-Aviv University

Psychotherapy Volume 28/Winter 1991/Number 4 563-71

Strategic thinking is not merely another therapeutic approach, but a practical concern of all approaches. This concern makes itself felt when goals are precise, and when therapy is hemmed in by constraints. Strategies are conceptual maps with three major components: ways of access to the goal, ways of dealing with resistance, and ways of mobilizing cooperation. Dialectical interventions are a strategic family in which two contrary therapeutic moves are coordinated so as to deal best with resistance and cooperation. Because of their dual character they illustrate aptly the elements of strategy that are often mixed in unidirectional interventions. Besides this illustrative role, dialectical strategy gives us an algorithm for dealing with the ubiquitous problem of mutual neutralization between the forces of resistance and cooperation. Ideally, it should be possible to potentiate any unidirectional move by an antithetical counterpart.

"Strategy" and its related concepts suffer from two ills: They are either bandied about as fashionable hazy terms, or made into a specific and exclusive approach to treatment, that of "strategic therapy," yet another school to swell the roll of the more than 400 extant ones (Karasu, 1986). Ifstrategic concepts are to make any real contribution and be saved from these two undesirable uses, they must be well defined and the principles ruling their application in a variety of therapeutic approaches set down. Omer and Alon (1989) pro-posed such a corpus of strategic principles as a common basis for dialogue between different treatment approaches. The present paper, following on this attempt, has a double purpose. To define the functional elements of strategic moves, and to present a family of interventions (the dialectical ones) that aptly illustrates the very structure of strategic thinking.

When Are Strategies Needed?

The term "strategy" is used at three levels of generality: At the lowest level, a strategy is a plan to solve a problem and attain a goal; at the middle level, it is an algorithm, that is, a general formula to create solutions for a given type of problem; at the highest level, it is the discipline, or way of thinking, that rules the creation of such algorithms and plans. In the present paper the word "plan" will be used to indicate the lowest level, and whenever needed we shall specify which of the other levels is intended. To clarify the distinction between a strategy as a specific plan, and a strategy as an algorithm, we may consider a Gestalt therapist treating a client with a decisional conflict. An algorithm for this type of problem might take the form, "decisional conflicts should be approached by the two-chair technique"; the specific plan for the problem would stipulate the roles to be embodied in each chair. Whatever the level of generality, however, the need for strategic considerations becomes greater the more precisely the goals be defined, and the more constrained be their pursuit.

a. Preciseness of goal definition. Hazy goals make clear strategies inapplicable. It is prepos-terous, for instance, to plan in detail for achieving goals such as "getting in touch with oneself", or "increasing self-fulfillment." Any clear plan would be faulted as restricting the scope of these goals and closing possible avenues towards self-contact or self-realization. Furthermore, even if one had a plan, how could one ever know whether the goal was being approached? Plans cannot be re-alized without feedback. In order to decide ra-tionally on pursuing, improving, or relinquishing them, we must know if we are making progress, but determination of progress requires clear definition of goals. Plans for encompassing hazy goals are therefore doomed to be hazy.

b. Constraints on pursuit of goals. Without limitations such as of time, money, acceptability of moves, or logistics, there is little need for planning. One may simply pursue the goals at one's own fumbling pace. Although psychotherapy is always constrained, as any treatment has limitations on what moves are legitimate, it is so to different degrees: An open-ended psychodynamic treatment is, for instance, less constrained (and therefore less in need of strategic planning) than a focused and time-limited one (Mann, 1973).

The foregoing clarifies the relationship between strategic thinking and symptom- or problem-oriented therapies. These therapies are more strategically oriented because they have clearer goals and usually limit themselves to shorter time spans. But strategy can become an issue in a relatively unfocused and open-ended therapy as well, when-ever limitations of money, time, physical capacity, or client availability make themselves felt. Strategic considerations are thus a matter of degree, and under proper circumstances may become prominent in any treatment.

Elements of Strategy

Essentially, strategy can be described as a conceptual map showing a) ways of accessing goals, b) ways for dealing with obstacles, and c) ways for mobilizing resources and help.

Ways of Accessing Goals

Therapy should set itself not a single goal, but a hierarchy of goals that makes for flexibility when progress is blocked (Omer & Alon, 1989). Any strategy requires a map of the territory within which we can move toward the goals. Within the map ways of approach are chosen, linking one's current position to the goals. Both the map and the ways of approach are determined by one's theory and therapy orientation, as well as by one's assessment of the case (according to the dictates of the theory). A behaviorist, for instance, will draw a map with descriptions of present and desired functioning, observations on stimuli, responses and reinforcement contingencies, and a list of potential reinforcers to mediate change. A psychodynamic therapist will draw a map of conflicting motivations, defense mechanisms, object relations, and observations on client—therapist interactions that are to be used in propitiating change. A family therapist's map will consist of coalitions, hierarchical crossings, communicational blocks, inter-personal boundaries, and family myths.

Dealing with Obstacles

Obstacles in general, and active opposition in particular, make strategic thinking mandatory. Although we may think strategically in areas un-colored by purposeful antagonism, such as re-search, or land exploration, it is the presence of opposed interests that makes for the typical strategic fields, such as war, sports, or diplomacy.

Resistance and conflicting interests are the daily bread of psychotherapy, and each orientation has its ways of reducing, avoiding, or deflecting the forces that block change. Some of these forces are directed at the therapist, while others operate within the client's life space. The need to deal with obstacles may necessitate digressions from a steady line of advance. At these times, in particular, it is crucial to keep in mind one's map and goals, lest therapy be led astray into blind endless chases after resistance and opposition.

Marshaling Alliances, Resources, and Help

The therapist's primary ally is the client. This is only a seeming truism, for therapists have a say in determining who the client should be. For example, when faced with referrals of unwilling partners, therapists may choose to demand inclusion in treatment of the person making the referral. But even strong alliances and willing clients may prove insufficient for change, if therapy fails to harness enough of their power to the work at hand. Striking and strengthening alliances, mobilizing the forces of change, and gearing them tightly to pursuit of the goals constitute the diplomacy and the logistics of therapy.

Strategy and Theory

The foregoing may help us understand the relationship between strategy and theory. Strategic thinking in psychotherapy has been sometimes presented as stemming from a particular theoretical approach. In the most influential attempt of this kind, Watzlawick, Weakland and Fisch (1974) have tried to derive strategic thinking from the theory of logical types and from Bateson's (1972) cybernetic concepts. On this view, strategy is the practical side of the theory, and strategic therapy is a specific therapeutic approach, or school.

Similar strategic principles, however, have appeared in areas as different as war, marketing, sports, and psychotherapy (Omer & Alon, 1989), and usually with no reference to any theory what-soever. Could it be that in all these instances of strategic thinking, the same underlying theory, although not openly articulated, was tacitly assumed? If this were so, one might expect that strategic thinkers should easily recognize and ac-claim the disclosure of their implicit theoretical model; moreover, this model should yield new strategic developments, beyond those that had been developed intuitively. None of this has happened. Strategically minded therapists often view the logical and communicational complexities that are said to underly their thinking with surprise and dismay, to say nothing of professionals in other fields. And, far from giving rise to new strategic developments, theoretical models of strategy are usually left in the shade as practitioners address a concrete job. Even the members of the MRI group, as their writings became more practically oriented, have avoided using their cumbersome theoretical concepts (Fisch, Weakland & Segal, 1982).

Strategic thinking should best be viewed as atheoretical, and as an unfolding of commonsense reasoning as one attempts to pursue goals under constraints. But strategic thinking does utilize ex-tant theories to provide it with maps of its fields of action. We need a behavioral, cognitive, psy-chodynamic, or interpersonal description of goals, obstacles, and resources in order to plan our moves. Thus, although it is atheoretical in its derivation, strategic thinking requires, for its work of plan-building, the specifications of theory-based maps. Being thus free (in its principles) from theoretical affiliation, but being in need (in its use) of the maps derived from the various psychotherapeutic approaches, strategy (as a way of thinking) can be viewed as a common ground promoting dialogue and integration in psychotherapy (Omer, 1989).

Strategy and Gimmick

The present characterization of the three func-tional elements of strategy may help to clarify the relationship between strategy and gimmick. In common parlance, "strategy" usually carries connotations of surprise and trickery, which are mainly due to the indirect ways (the gimmicks) that are used sometimes for dealing with re-sistance. Although these usually constitute no more than a fraction of the treatment, they tend to lend a devious coloration to the whole. In the dialectical interventions to be described, the role of the gimmick in dealing with resistance will be shown as it dovetails with the more straightforward strategic elements, maximizing their impact. An analysis of these interventions will clarify the role of the gimmick within the strategy. Although often giving the impression of magical solutions for otherwise intractable problems, gimmicks usually play a subsidiary role, and a closer look will show how the gimmick actually paves the way for the more commonplace elements in their work of change.

Dialectical Interventions

Dialectical interventions are treatment strategies that embody two antithetical moves in such a way that as the pendulum swings from one to the other, change forces are mobilized and resistances neu-tralized. The term "dialectical" is used in its He-gelian sense, meaning that these interventions consist of two coordinated contrary movements that may be thought of as a thesis and an antithesis. Although sometimes the intervention aims at giving maximum power to one of the polar movements, at other times it aims at an emerging synthesis. Dialectical interventions illustrate well the basic elements of strategy, for, being built of very distinct moves, they set apart the constitutive elements of strategy that often mingle confusedly in simpler interventions. The dialectical polarity deals most elegantly with the contrary vectors of opposing and allied forces: One hand of the intervention fends off or disarms the former, while the other builds up and impells the latter.

Good and Bad Therapists

In this dialectical intervention, the client is faced with two therapists, the one challenging, critical, and obnoxious, and the other supportive, opti-mistic, and warm. The "bad" therapist criticizes the client, and demands either a very strict treatment regimen or the relinquishment of treatment efforts. The "good" therapist, often silent at the beginning, slowly emerges as the protector from the "bad" one's aspersions, and supports the client's rightsfor independence, participation, and trust (Hoffman & Laub, 1986).

In a family case described by Hoffman and Laub (1986), the "bad" therapist declared to a five-year-old girl (brought to treatment for elective mutism) and her parents, that she was childish, stubborn, and incapable of behaving as other children of her age. The "good" therapist disagreed indignantly, and told the "bad" therapist that he had no right to pass judgment on the girl on the strength of a single meeting. The "bad" therapist answered that he was willing to wait to prove his case, and, taking out a pack of candies from a cupboard, challenged the girl and her younger brother to a bet: He said that the girl wouldn't speak one single word to the teacher in kindergarten during the coming week; if she did, the two kids would get the candies, if not, they would have to bring him another pack. He added that he loved candies and would be delighted to have a new pack all for himself. When the family left, the "good" therapist, waiting behind the door, gestured to the girl to come to her, and told her in secret that the other therapist was wrong in thinking her childish and stubborn, and that he would yet be sorry for having said that. With a collusive wink, she (the therapist) parted from the girl until the coming week. Treatment progressed to a quick positive conclusion, followed by the "bad" ther-apist's apologizing to the girl, since he had been clearly in the wrong and had been taught a lesson.

This strategy was built of two core interventions that might have been somewhat effective individually: The "good" therapist developed a warm therapeutic alliance that would, in time, foster the girl's confidence and sense of security; the "bad" therapist channeled to himself the girl's antagonism, but in such way that in order to defeat him, she would have to talk.

The dialectical strategy coordinated these core interventions by building upon the girl's conflicting motivations. The mutistic child is usually torn between two opposing forces: The will to speak, that is based on the wish to become like other kids and perhaps to satisfy the parents' expecta-tions, is countered by the opposing tendency, that is due to a blend of anxiety and negativism. Whenever the first is aroused, the second blocks it, resulting in a tense immobility. Following this assumptive map, the therapists build a dialectical strategy that restored movement by taking these forces apart. The negativistic drive was deflected toward the "bad" therapist, while the will to speak was pulled toward the "good" one. The previously antagonistic forces thus became synergistic, and the "bad" therapist's facial act was put in the service of the "good" therapist's positive influence. Both negativism and cooperation were now served by improvement, making the coordinated whole stronger than the sum of its parts.

Taking Turns

In this dialectical strategy, two mutually ob-structive forces are pulled apart by having them alternate. Minuchin, Rosman, and Baker (1978) illustrated this approach with families in which the two parents, the one permissive, the other authoritarian, neutralized each other. With anorexia nervosa, for instance, one of the parents would be told to make the girl eat, while the other was prevented from interfering. If thefirst parent failed, the second was given a try. Each parent's efforts were allowed to proceed far beyond the point where they would usually be stopped by the other parent, thus broadening the swing of the family pendulum. If both parents failed, the therapist would declare the girl the family strongperson, but would add that she ruled as a destructive tyrant. By countering the mutual jamming of the parents' efforts, this strategy gave each a better chance of succeeding. Decreeing the girl the home tyrant also had a therapeutic effect: It united the parents, raising the possibility of a synthesis that transcended the two polar positions.

In the two-chair technique of Gestalt therapy, a client who displays contrary tendencies is asked to role-play first one, and then the other, each with no interference from its counterpart. After playing both parts, the client is not asked to choose between them, but to "own up" to both. This is an injunction for a new synthesis, transcending the two options. Similarly, in the "odd and even days" ritual of the Milano school of family therapy (Tomm, 1984), whenever the spouses are at log-gerheads about a daily issue, the prescription is given that one of them is to have complete control on odd days of the week, and the other, on even ones. On Sundays, the couple is to act "sponta-neously" (again, an indirect suggestion for a new synthesis).

The strategic elements in these examples are similar. The map that guides the therapists is the assumption that the conflicting forces in the patient system (the opposed styles of parenting in the family examples, and the client's contrary tendencies in the Gestalt example) cancel each other.

This jamming is untrammeled by alternation. By confirming and legitimizing both sides, this strategy increases the client's feelings of acceptance (in the family examples both sides are declared right, whereas in the Gestalt example, the client's previous feeling of being only half in the right gives way to a fuller personal endorsement) and their readiness to cooperate. The gimmick of having the sides take turns is thus put in the service of the therapeutic alliance and of the patient's sense of efficacy and worth.

The Two-Stage Model

In this approach, as in the previous illustrations, the two antithetical moves are applied in succession, but now the first paves the way for the success of the second. The accent, in this strategy, always falls on the second move.

Erickson (Haley, 1973) used this method with a patient who while requesting hypnosis implied that Erickson would surely fail, as three well-known hypnotists had failed to make him uncon-scious or control his reactions. Erickson asserted that he had never met an unhypnotizable person before, and thereupon started on an authoritative induction backed by such flamboyant devices that the crassness of his failure grew by the moment. After many ineffective attempts, Erickson con-fessed to the client's unhypnotizability. As the latter nodded with a pleasure a little mixed with guilt at the old man's discomfiture, Erickson sug-gested that, maybe, precisely because of his strong ego, he might be able to learn self-hypnosis. As the client became interested, Erickson proceeded to teach him, in a highly permissive manner, how to use imagery to develop hypnotic phenomena and to deal with the problem for which he had asked help in the first place.

In a case under my supervision, a middle-aged couple asked for help with their fifteen-year-old son who had dropped out from school, and, for more than a year, used to spend his days at home playing computer games. Their unceasing attempts to make him go back to school (including seven successive therapeutic failures) had proved un-availing. It was assumed that the parents' relentless attempts to treat and convince the boy had created a tug of war, in which the child showed himself by far the stronger party. The parents, however, could not leave the boy alone, as this signified to them that they had despaired of him and given up on their obligations. This assumptive map guided the therapist in formulating the following plan: The parents were instructed to enter the boy's room at five every morning, and to remain there until seven, taking turns in bewailing their fate and pleading for change. After a week of lamentations, the parents felt unable to go on. Thereupon the therapist declared that in their eight treatments they had done all that was humanly possible to rescue their son, and that it was now their duty to the family to restore their depleted energies and improve their own quality of life. They should tell the boy that he had won, that he was stronger than they, and that school would no longer be mentioned. The two were deeply moved by the therapist's absolution. Two months later they found, to their astonishment, that the boy had registered on his own at a new school. A year later he was still studying.

A similar sequence was employed with a number of rebellious teenagers (between 12 and 14) whose behavior the parents, holding to rigid norms, had failed to compromise upon, accept, or curb. The parents were asked whether they were willing to negotiate with the child, or would rather wage an all-out fight for their principles. If they chose the second option they were asked to commit them-selves most bindingily to a six-week effort of highest priority. They were also asked to find allies (usually relatives) for the coming battle. Upon their commitment, a detailed program was developed that included accompanying the child to school and back (if truancy were a problem), talking the child to work with one of the parents, sitting together for homework for a few hours every day, and staying with the child all through the weekend. Obstreperous or violent reactions were to be dealt with by calling in the ally (if necessary), and holding the child pinned to the bed for two hours, without a word. This first stage, which led to positive change in itself, was followed by a second: Exhausted from the six weeks of blood, sweat, and tears, both sides proved quite amenable to negotiation and compromise, which had seemed all but unattainable at the be-ginning.

Another double-staged strategy pioneered by Erickson (1954) has, as its core intervention, the imagery technique of future time progression. In this technique, clients are guided through an imaginary trip to the future in which they view themselves coping successfully with their problem. In the two-stage model, this positive imagery is preceded by a trip to the past in which they are to recall some incidents in which they felt most devastated by their problem, and to immerse themselves in feelings of disgust, self-blame, and humiliation. These incidents are to be kept in mind until the clients feel absolutely ready to do just anything in order to overcome their liabilities. The positive future trip begins when they indicate that they have reached that readiness.

Each of the polar moves in these examples would make for an acceptable intervention in itself. Thus, there is some value in both the authoritarian and the permissive approaches to hypnosis, the compromising and the disciplinarian attitude to rebellious children, and the aversive and optimistic approaches to guided imagery. The double-stage strategy becomes relevant when unless one of the options be disposed of, it inhibits the other. Thus, in the hypnotic case, until the client's view that hypnosis meant loss of control had been disposed of, it would probably plague any attempt to treat him that way. In the teenager cases, the mirage of the child's unconditional surrender had to be discarded for compromise to become possible. And in the imaginary trip technique, unless the patients' tendency to raise images of failure were written off, any positive imagery was in danger of contamination. These were the assumptive maps that underlay the dialectical strategy. In the first example, the smashing failure of the authoritarian induction discharged the client's resistance, so that the permissive approach could proceed un-disturbed; in the family examples, the sacrifices made in the first stage reduced the parents' aversion to compromise or to giving-up; and in the imagery example, since the clients themselves indicated that they had had enough impotence and humil-iation, it was unlikely that they would resist the optimistic trip by resorting again to images of defeat. In all examples, neutralizing resistance by the first move released the readiness to cooperate in the second.

The Direct-Paradoxical Mix

In this strategy a direct intervention is contrasted with a paradoxical one, so that each potentiates the other. For instance, in marital therapy, while the husband is trained in self-control to learn how to avoid quarrelling, the wife is paradoxically enjoined to continue teasing him, so as to help him exercise the new skills. Or, as a dependent wife of a withdrawing husband is enjoined to do things by herself, the husband is paradoxically told to withstand the urge to be nice to her, so as to help her to become autonomous (Lange, 1989).

All by itself, the direct intervention would often be resisted, for enjoining one of the spouses to change makes him or her feel blamed, while the other seems justified by the therapist and comes out victorious. Attempts to balance interventions precisely, so that each spouse feels that the other is being equally blamed and changed are highly unstable and hard to maintain. This common quandary of marital therapy serves as the map for the dialectical strategy. Having to behave teasingly or in a withdrawn manner as homework gives the "offending" spouse little sense of triumph or righ-teousness, and this reduces the resistance of the "victimized" spouse. The direct move, on the other hand, motivates the "offending" spouse for the paradoxical one, serving as its rationale: He or she is to continue being obnoxious in order to help the victimized one to develop new skills. As noted by Lange (1989) this rationale is twice ef-fective, since it is hard for a spouse to reject the injunction (for this would be unhelpful), but it is almost impossible to tease in order to help. An effective rationale for a paradoxical prescription should achieve precisely this: To keep the patient from dismissing it, while at the same time making compliance all but impossible.

Sex therapy illustrates this direct-paradoxical mix when both moves are addressed at the same person. In treating male impotence, for instance, attempts at penetration are strictly forbidden (the paradoxical component), while the couple are given a progression of stimulating sensual exercises (the direct component). The assumptive map behind this strategy stipulates that performance anxiety underlies impotence and prevents intimacy. For-bidding penetration allays anxiety thus reducing resistance to physical contact. On the other hand, the sexual urge bred by the exercises makes the paradoxical prescription forbidding penetration ever harder to comply with. The two moves support each other The paradoxical one disarms resistance and the direct one loads up the paradox with the growing sexuality. The whole is, once again, stronger than the sum of its parts.

The Anti-Expectational Twist

It is a professional truism that therapy must counter the neurotic expectations of clients. When therapists, however, do not merely disconfirm dysfunctional expectations, but, first, nurse, rear, and inflate them, only better to refute them more smashingly, we then have a clear dialectical strat-egy. The anti-expectational twist differs from other double-staged strategies, in that the first move is not therapeutic in itself. On the contrary, if left to itself, it would exacerbate the client's dys-functional expectations; its raison d'itre is only to increase the impact of the coming disconfir-mation.

This strategy made an early appearance in psy-chotherapy in Aichhorn's classical "Wayward Youth" (1963). One of the youngsters in the au-thor's school remained unapproachable and isolated behind a smooth wall of seeming self-sufficiency, and a rigid belief that all grown-ups were out to get him. As a last resort, Aichhorn engineered a situation in which the boy couldn't withstand the temptation to run away. The boy fell into the trap and vanished for ten days (this was much longer than Aichhorn had intended, and for a while the stratagem seemed to have backfired). In the evening of the tenth day the boy knocked at Aichhorn's door in a state of exhaustion and disarray, and in tense expectation of punishment. Aichhorn asked him instead, "How long has it been since you had something to eat?" As expected, the boy was hun-gry, so Aichhorn brought him to the dining room, where his family was at supper, and had a place set for him. The boy was so upset that he could not eat. As he struggled unavailingly with the food on his plate, Aichhorn helped him by taking him to the kitchen, where he ate his fill. After dinner Aichhorn said that it was too late to go back to the dorm and fixed him a bed in the hall, patting his head and wishing him a good night. The boy's relationship with Aichhorn and the school changed dramatically and the way for re-habilitation was opened.

Alexander and French (1946) gave a theory and a name to this dialectical variety, in the concept of "corrective emotional experience." This shortcut to psychotherapy consisted in therapist's first stimulating the client's transferential expectations to a high pitch, and then responding in ways dia-metrically opposed to them. For example, a young man, suffering from duodenal ulcers, who had learned from his mother that all dependent needs were invariably rejected, led a spartan and com-petitive life, allowing no one to participate in his troubles. His female therapist played a guiding and supportive role in order to foster his dependent yearnings and exacerbate his irrational expectations of an eventual rebuff. At a time when the patient underwent an acute life stress and developed severe rejection anxiety, she suddenly trebled the fre-quency of sessions, encouraged the expression of dependent strivings, and instructed his wife (who had been previously checked to be capable of playing such a role) to be highly caring and pro-tective toward him. After the crisis, the therapist worked with the patient on developing legitimate ways for expressing and fulfilling dependency needs.

A final example will illustrate some of the ther-apeutic risks with which this strategy can be at-tended. A woman asked for my help in her recent marriage with a widower, with whom she had a warm relationship, but who angrily pressured her to relinquish all previous ties. Three years earlier the husband had suffered a severe cardiac infarct, and anxiety about his heart, though never men-tioned, pervaded the home atmosphere. He came to some therapy sessions, but stuck to his belief that any contacts on her part led her away from the marriage. After three months of mostly in-dividual therapy, the wife appeared in the office extremely agitated, and told me that her husband's tyranny had finally made her decide to leave him. To complicate matters I was planning to leave the country for a sabbatical in three weeks, and this gave urgency to any therapeutic course (or lack of one). I asked her if she would be willing to try one last therapeutic fling to make him change. As she agreed, I instructed her to go out of the house for four evenings the coming week. She was to tell the husband that this initiative had my blessing, and that I wanted to meet him. He came to my office after five days and, while still standing, asked me whether I had incited his wife to her outrageous behavior. I answered that if he meant her outings with girlfriends and family, that was true. He sat down, pointed his finger at me, and started on a twenty-minute tirade, threatening to bring me to court, accusing me of arrant immo-rality, blaming me for the destruction of his home, and telling me that if he were a little less civilized he would beat me to a pulp. All through his ac-cusations I said little, except to confirm some concrete details. As he stood up, preparing to leave, I said that I had one small thing to say. He turned to me scornfully and I asked him to sit down, whereupon I delivered myself, slowly, from the following previously memorized speech: "Ever since I met you and your wife, I was impressed by the value of your marriage. I am sure that a divorce would be disastrous to her, and as for you, it would signify your spiritual and perhaps physical death, so that no pains are to be saved in saving the marriage. Your reactions to your

wife's outings are perhaps the only humanly pos-sible ones. When we feel cornered and our life threatened, we hit back. For you, any step your wife makes away from home, no matter to what purpose, seems to threaten your very life and you react as you must. The pity and the irony of it is that only if you could do what is almost surely impossible, to give your wife a sense of freedom, could you save this most precious marriage of yours." I refused to listen to his expressions of regret, telling him only that his behavior in the session had been inevitable. I was notified by letters that the jealous scenes disappeared and that the marriage entered a positive phase.

So long as the client's attitude remains suspicious and avoidant, all therapeutic efforts will be dis-counted from start. This assumption maps out the therapeutic route in the anti-expectational twist: The boy's suspicions in Aichhorn's case had to be dismantled, the young man's certainty of re-jection in the Alexander and French's case had to be refuted, and the husband's attitudinal block in the last example had to be loosened, for any therapeutic messages to be registered at all.

In the first two examples, mere is a clear dis-tinction between the gimmick (that dealt with the chief obstacle to therapy) and the slower therapeutic work that followed (rehabilitation in the first case, and the development of legitimate ways for ex-pressing dependency in the second). The final case, even though it is one of those rare examples of an effective single-shot intervention, illustrates all the basic strategic elements: An assumptive map, stipulating that the husband's acute reactions were due to a catastrophic fear of abandonment and death, a ploy to induce and shatter resistance, and the mobilization of the patient's will to change by presenting a possible way to save the marriage bolstered by his need to redeem the debt he had incurred toward the therapist by his unjust ac-cusations.

Conclusion

The difference between unidirectional strategic interventions and dialectical ones, is that the former are either built of a single movement, or of a series of stages that follow smoothly from one another, with no directional changes. When a family therapist, for instance, supports all members and reframes problem behaviors as contributing to family unity, the same move reduces opposition (by allaying fears of blaming or pressure) and enhances the therapist's standing, thus creating the necessary leverage for the work ahead. Sim-ilarly, a behavior therapist, in building new re-inforcement contingencies, takes care to neutralize possible advantages from symptomatic behaviors (thus dealing with possible obstacles to treatment) and to present incentives for the development of adaptive behaviors (thus mobilizing positive mo-tivations) in the same move. Even paradoxical strategies are usually unidirectional. Thus, when a therapist consistently prescribes the symptom to a client, being seemingly baffled by improve-ments and predicting relapse, the same move deals with resistance and creates motivation for change (the resistance being turned into the major mover for therapeutic progress).

In distinction from these, the dialectical strategy mirrors in its structure the opposition between the forces of resistance and cooperation. For this reason, what is often blurred in other strategies, strikes the eye in dialectical ones. We can now understand why dialectical interventions seem more "strategic" than unidirectional ones; Not because they deal better with toward and untoward forces, but because they display the elements of strategy with the greatest clarity. Dialectical interventions are thus the perfect illustration for strategic prin-ciples.

This, however, does not exhaust the contribution of dialectical interventions. As can be seen in the examples above, it is often possible to build a dialectical strategy upon an unidirectional one, obtaining a stronger composite. Dialectical strat-egies are thus empowering devices. Ideally, it should be feasible to enhance dialectically any unidirectional strategy, turning it into a double-pronged intervention. We do not do so because it is often difficult enough to design and apply a simple strategy for many problems, to say nothing of dialectical ones! Yet, it is important to keep in mind that the dialectical strategy is an algorithm

for dealing with the ubiquitous problem of mutual neutralization. For any undirectional plan, it is possible, in principle, to devise an empowering antithetical move to drive apart the forces of re-sistance and cooperation. Whenever we feel a lack of therapeutic leverage, the effort needed to apply this algorithm may be worthwhile.

Two final words about theories and gimmicks: The illustrations in this article, deriving from ap-proaches as diverse as the psychodynamic, sys-temic, Gestalt, and cognitive-behavioral, argue for the independence of strategic thinking from any specific psychotherapeutic theory. Theories were neededto provide the therapists with workable maps, but not to dictate the strategic principles as such. The examples above suggest that strategic thinking has no school affiliation, and can therefore fulfill an integrative role in psychotherapy (Omer & Alon, 1989). And as for gimmicks: Unless these be defined and explained, they will remain only as so many quirks and freaks, for no profession can be based upon inspirational fireworks. The present illustrations show how some tricky ways of dealing with resistance may play a useful role, if they be derived from a therapeutic assumptive map, and geared to enhance the workings of the more straightforward therapeutic elements. A fruitful approach to the presentation of a therapeutic gimmick should then be neither an impatient dis-missal nor a gasp of admiration, but a critical inquisition into its derivation from the problem's analysis, and its role in the treatment plan.

References

ALEXANDER, F. & FRENCH, T. M. (1946). Psychoanalytic therapy, principles and applications. New York: Ronald. BATESON, G. (1972). Steps to an ecology of mind. New York:

Ballantine. ERICKSON, M. H. (1954). Pseudoorientation in time as a hypno-therapcutic procedure. Journal of Clinical and Experimental Hypnosis, 2, 261-283.

FISCH, R., WEAKLAND, J. H. & SEGAL, L. (1982). The tacticsof change: Doing therapy briefly. San Francisco: Jossey-Bass.

HALEY, J. (1973). Uncommon therapy: The psychiatric tech-niques of Milton H. Erickson, M.D. New York: Norton.

HOFFMAN, S. & LAUB, B. (1986). Paradoxical intervention using a polarization model of cotherapy in the treatment ofelective mutism: A case study. Contemporary Family Ther-apy, 8, 136-143.

KARASU, T. B. (1986). The specificity versus non-specificity dilemma: Toward identifying therapeutic change agents.American Journal of Psychiatry, 143, 687-695.

LANGE, A. (1989). The "help" paradigm in the treatment of severely distressed couples: A combination of paradoxical and problem-solving elements. The American Journal of Family Therapy, 17, 3-13.

MANN, J. (1973). Time-limited psychotherapy. Cambridge,MA: Harvard University Press.

MINUCHIN, S., ROSMAN, B. L. & BAKER, L. (1978). Psy-chosomatic families: Anorexia nervosa in context. Cam-bridge, MA: Harvard University Press.

OMER, H. (1989). Specifics and nonspecifics in psychotherapy.American Journal of Psychotherapy, 43, 181-192.

OMER, H. & ALON, N. (1989). Principles of psychotherapeutic strategy. Psychotherapy, 26, 282-289.

TOMM, K. (1984). One perspective on the Milan's systemicapproach (Parts I and II). Journal of Marital and Family Therapy, 10, 113-125; 253-271.

WATZLAWICK, P., WEAKLAND, J. H. & FISCH, R. (1974).Change: Principles of Problem Formation and Problem Resolution. New York: Norton.

------

Correspondence regarding this article should be addressed to Haim Omer, Department of Psychology, Tel-Aviv University, Ramat-Aviv, Tel-Aviv, Israel.

www.psychspace.com心理学空间网
«辩证心理治疗的原理和方法 DBT 辩证行为疗法
《DBT 辩证行为疗法》
奥马的辩证方法»