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.