Brief strategic therapy

1. Introduction

Version followed: the Advanced Brief Strategic Therapy (BST) model of Giorgio Nardone and the Centro di Terapia Strategica (CTS), Arezzo, Italy, as set out in Nardone & Portelli (2005) Knowing Through Changing and the CTS disorder-specific protocols published as research protocols in 2016 (OCD) and 2019 (bulimia and binge eating). This is a development of the Palo Alto MRI brief therapy of Watzlawick, Weakland and Fisch, and of Nardone & Watzlawick (1993) The Art of Change. Where this guide draws on the earlier model or on Spanish-language secondary reviews, it says so. [source: Nardone & Portelli 2005, ch. list and ch. 1, 6; Pietrabissa et al. 2016; Pietrabissa et al. 2019]

What it is. BST is a short, directive, problem-focused psychotherapy. It does not search for causes. It works out how a problem keeps itself going here and now, then breaks that cycle with planned maneuvers. These are reframings delivered through a structured "strategic dialogue", plus prescriptions the client carries out between sessions. For common disorders (panic and phobias, OCD, eating disorders, depression, children's behaviour problems and others), CTS has standardised protocols that map each disorder's typical "form of persistence". [source: Nardone & Portelli 2005, ch. 6 intro; Pietrabissa et al. 2019]

How change happens. A problem persists because of the client's attempted solutions: avoiding, asking for help or reassurance, controlling, ritualising. The same is true of the people around them, and together these form a self-maintaining loop. The authors call this a dysfunctional perceptive-reactive system: a fixed way of perceiving that drives fixed reactions, which then confirm the perception. The therapist first follows this structure, then turns its own force against it, typically through paradox. The client then has a concrete corrective emotional experience that changes perception first, and understanding follows the change rather than preceding it ("knowing through changing"). [source: Nardone & Portelli 2005, ch. 1, 6; Pietrabissa et al. 2019; Adobatto 2024]

2. Framework

The advanced model has four stages. The CTS describes them in game terms, from "start of the game" to "end of the game". The first session covers stage 1 and usually begins stage 2. [source: Levold 2010 summarising Nardone 2004; Adobatto 2025; De la Cruz Gil 2021] The detailed "sequential scheme of the advanced model" (Nardone & Portelli 2005, ch. 4) is not drawn on here [uncertain]. The stage content below comes from published summaries and case reports.

Stage	Goals	Main tools	Typical timing
1. First session / problem definition ("start of the game")	Build the relationship by matching the client's language and logic. Define the problem in operational terms (what, where, when, with whom, how). Identify the perceptive-reactive system and the attempted solutions of client and others. Agree concrete goals.	Strategic dialogue (questions, paraphrases, evocative language, summary), first reframings, first prescriptions (often logbook, conspiracy of silence, how to make it worse, miracle fantasy).	Session 1, sometimes 2
2. Unblocking the symptom	Produce the first concrete change, then redefine it so it spreads into further change. If there is no change, block the failed solutions and loosen the rigid perception with new maneuvers.	Paradoxical and direct prescriptions, symptom prescription, counter-rituals, metaphors. Language is hypnotic, suggestive and injunctive.	About sessions 2–5
3. Consolidation	Measure and consolidate gains. Anticipate setbacks. Encourage a more flexible response to reality. Move toward a more ordinary dialogue.	Direct and indirect prescriptions that build autonomy, redefinition of gains, work on resources.	About sessions 6–7
4. End of treatment / autonomy ("end of the game")	Explain the strategy that was used. Credit the client with the change and return responsibility to them.	Final explanatory session, then follow-ups.	Last session; follow-ups at 3, 6 and 12 months

[source: Adobatto 2025 citing Nardone & Portelli 2006 and De la Cruz Gil 2021; De la Cruz Gil 2021; Pietrabissa et al. 2019]

Session count and format.

Individual, face-to-face. Family members are drawn into some prescriptions, such as the conspiracy of silence. [source: Pietrabissa et al. 2019]
Panic and phobias: CTS reports a mean of about seven sessions. [source: Nardone & Portelli 2005, ch. 6]
Research protocols: 8–10 sessions of 45–50 minutes, every two weeks, for OCD and eating disorders. [source: Pietrabissa et al. 2016; 2019]
A published GAD case used 8 weekly one-hour sessions, then a check at 3 months. [source: De la Cruz Gil 2021]
The wide spacing is deliberate: it gives prescriptions time to work. [synthesis]

Moving between stages.

1 → 2: the problem is defined operationally, the client has confirmed the therapist's paraphrases, goals are agreed, and the client has accepted the first prescription. [source: Adobatto 2024; De la Cruz Gil et al. 2025]
2 → 3: the symptom is "unblocked", meaning there is a clear, client-reported reduction of the key symptom or failed solution. In the published GAD case this happened at session 4. Nardone & Portelli report 81% of panic and phobia cases unblocked by session 5. [source: De la Cruz Gil 2021; Nardone & Portelli 2005, ch. 6]
No change in stage 2: do not repeat the same maneuver. Change the maneuver: block failed solutions more directly, or switch to paradox. [source: Adobatto 2025] A practical rule: if nothing has moved after two prescriptions, re-examine the problem definition and the client's collaboration type. [synthesis]
3 → 4: gains are stable across sessions, setbacks have been anticipated and managed by the client, and the client can say what they now do differently. [synthesis based on Adobatto 2025]

3. Guiding principles

The solution adapts to the problem, not the reverse. Nardone's wording: "it is always the solution that adapts to the problem". In practice, choose maneuvers to fit this problem's persistence, not your theory. [source: Nardone & Portelli 2005, ch. 1]
Knowing through changing. You understand a problem by how it responds to your interventions. In practice, treat every prescription as an experiment and adjust after reading the results. [source: Nardone & Portelli 2005, ch. 1–2; Adobatto 2025]
Ask how, not why. The focus is on how the problem works now, not on its origins. In practice, spend your questions on mechanics: what, when, where, with whom, what the client does next. [source: Adobatto 2025 citing Nardone & Salvini; Pietrabissa et al. 2019]
Attempted solutions become the problem. In practice, map what the client and the people around them do to fix the problem, then block or reverse those efforts. [source: Paoli 2014 preface/intro; Nardone & Portelli 2005, ch. 6]
Two levers: block failed solutions, and build effective ones. In practice, every session should either interrupt a failed solution or set up a new experience. [source: Paoli 2014]
Constructivism and second-order reality. Interventions target the meaning the client gives events, not the facts. In practice, reframe meanings and do not dispute facts. [source: Nardone & Portelli 2005, ch. 1; Paoli 2014; Cardona Reyes 2015]
Follow the persistence, then reverse it. Use the pathology's own force to produce change. In practice, prescribe more of, or a structured version of, what the client already does, so that it turns against itself. [source: Nardone & Portelli 2005, ch. 6]
Feel first, understand later. Change comes from a corrective emotional experience, not from explanation. In practice, give fewer rational explanations and more experiences, images and tasks. [source: Pietrabissa et al. 2019; Adobatto 2024]
Non-ordinary logic. Paradox, belief and self-deception are used deliberately. In practice, be ready to prescribe the symptom or "worsening" when direct requests fail. [source: Cardona Reyes 2015; Paoli 2014 contents; De la Cruz Gil et al. 2025]
Never contradict the client's logic. First show that their logic makes sense, then shift it from inside. In practice, agree before you reframe. [source: Pietrabissa et al. 2016; Adobatto 2024]
Injunctive, performative, evocative language. Use metaphors, anecdotes, aphorisms, repetition and a marked tone, especially early in therapy. In practice, speak to produce an effect, not to inform. [source: Pietrabissa et al. 2016; 2019]
Discoveries are made together. Present the reframe and the prescription as conclusions the client has reached with you. In practice, summarise their answers and then propose the task. This also reduces resistance. [source: Adobatto 2024]
Match the client's way of collaborating. Use rational, demonstrative communication with collaborative clients, indirect and evocative maneuvers with clients who are willing but blocked, and paradox with non-collaborative clients. In practice, assess collaboration in session 1 and choose your register to fit. [source: Adobatto 2024]
Protocols are maps, not scripts. Disorder protocols list typical attempted solutions and matching maneuvers, but they self-correct based on the client's response. [source: Adobatto 2024; Nardone & Portelli 2005, ch. 6–7]
Brevity and autonomy. Credit the client with the change and close with an explanation. In practice, plan the ending from the start. [source: Adobatto 2025]
Supervision and fidelity. CTS research uses video recording and supervision by senior therapists. If you are new to the model, record sessions (with consent) and get supervision. [source: Pietrabissa et al. 2016; 2019]

4. Intervention inventory

The inventory has three parts: (A) the strategic dialogue, which the first session is built on; (B) general maneuvers used across problems; (C) protocol-specific prescriptions. The precise wording of the CTS manuals was not available, so all example language is illustrative and paraphrased. Durations and frequencies are given only where a source states them; otherwise they are marked [synthesis].

A. The strategic dialogue (first session and beyond)

The strategic dialogue is a five-step sequence. Nardone & Salvini's book on it (The Strategic Dialogue) is not drawn on here [uncertain]. The steps below come from Nardone 2004 as summarised by Levold, Spanish reviews citing Nardone & Salvini and Nardone & Portelli, and Fronzetti Colladon's applied summary. Sources disagree on step labels: one review gives the first step as "questioning capabilities" [uncertain]. The sequence runs as a funnel, from general to specific, and is repeated in cycles of two or three questions, then a paraphrase. [source: Levold 2010; Adobatto 2024; De la Cruz Gil et al. 2025; Fronzetti Colladon]

A1. Strategic questions with an illusion of alternatives

Purpose: to map how the problem works and its attempted solutions quickly, while leading the client to discover it for themselves. Used throughout session 1 and whenever the problem needs redefining.
Steps:
1. Ask closed questions that offer two alternatives you have built yourself, not open questions. [source: Levold 2010; Fronzetti Colladon citing Nardone & Salvini 2018]
2. Start broad: is the problem constant or occasional, at home or also at work, alone or with others? [source: Fronzetti Colladon]
3. Narrow toward attempted solutions. Ask whether the client avoids or faces the situation, asks for help or manages alone, and whether others help or not. [source: Fronzetti Colladon; Nardone & Portelli 2005, ch. 6]
4. Build each pair so that either answer tells you something useful. Whichever the client chooses shows a maintaining solution. [source: Adobatto 2024]
5. After two or three questions, move to A2. [source: Adobatto 2024]
Example language (illustrative): "When the fear comes, do you tend to get away from the situation, or do you stay and try to control it?" "When you ask your partner to come with you, does it make you feel calmer, or does it remind you that you can't go alone?"
Watch for: answers that do not fit either option. Take these as data and build a new pair. Avoid leading the client toward an answer they do not hold [synthesis]. You know it is working when the client starts finishing your sentences or volunteers the pattern.

A2. Restructuring paraphrase

Purpose: to sum up how the problem works in a way that makes the vicious circle visible, and to get the client's agreement step by step.
Steps:
1. Restate the client's last answers in their own words, adding a small new angle. For example, you might link their avoidance to the problem getting worse. [source: Fronzetti Colladon; Adobatto 2024]
2. End the paraphrase with a check question: "Is that right, or am I mistaken?"
3. Wait for clear agreement before going on. Without it, return to questions. [source: De la Cruz Gil et al. 2025, citing Nardone & Portelli 2007]
Example language (illustrative): "Let me check I've got it. When the fear rises you leave, and you feel better at once. But each time you leave, the next time feels harder. Is that how it goes, or have I got it wrong?"
Watch for: half-agreement ("sort of"). Treat it as a no and narrow further. A string of firm yeses builds the agreement that the prescription will rest on. [source: Adobatto 2024]

A3. Evocative language

Purpose: to make the client feel the cost of the failed solution (aversion) and the appeal of the new path, beyond understanding it. [source: Fronzetti Colladon; Adobatto 2024]
Steps:
1. Choose an image, metaphor, anecdote or aphorism that fits the client's own vocabulary and world. [source: Adobatto 2024]
2. Place it straight after an agreed paraphrase, so it amplifies something already accepted.
3. Say it slowly and with emphasis, perhaps repeating the key phrase. Early in therapy, the CTS deliberately uses a hypnotic, suggestive delivery. [source: Pietrabissa et al. 2016; Adobatto 2025]
Published examples (paraphrased): avoidance is like fertilising a plant you want to stop growing. A wound must be cleaned, and then it heals by itself. [source: Adobatto 2024, case reports] Another example from a source is "the more you avoid the fearful situation, the more frightening it becomes". [source: Pietrabissa et al. 2016]
Watch for: a visible emotional reaction (a pause, a wince, a smile) means it landed. An intellectual debate means you have lost the evocative register, so return to images. [synthesis]

A4. Summary to redefine

Purpose: to pull the agreed pieces together into a new definition of the problem that the client experiences as their own discovery. [source: Adobatto 2024; Fronzetti Colladon]
Steps:
1. List the small agreements in order.
2. Draw the conclusion they lead to. The usual form is that the client's own solutions keep the problem going.
3. Ask for confirmation of the whole summary.
Example language (illustrative): "So, putting together what you've told me: the avoiding, the phone calls to your mother, and checking your pulse. Each of these gives you relief now and makes the next attack more likely. Does that fit?"
Watch for: if the summary is rejected, one earlier paraphrase was not really accepted. Find it and rework it. [synthesis]

A5. Prescription as joint discovery

Purpose: to turn the redefinition into a concrete task between sessions. Change is meant to happen through action outside the room. [source: Adobatto 2024; Pietrabissa et al. 2016]
Steps:
1. Introduce the task as following logically from what the two of you have found.
2. Give precise instructions for when, where, how often, what to write and what to bring back. [source: Nardone & Portelli 2005, ch. 6, logbook]
3. Use injunctive and post-hypnotic style phrasing, and repeat the key instruction. [source: Pietrabissa et al. 2016]
4. Get an explicit commitment. Ask the client to repeat the task back to you. [synthesis]
Example language (illustrative): "Given what we've discovered, I'd like you to do something that may seem odd. Do it exactly as I say, no more and no less."
Watch for: a vague agreement ("I'll try"). Tighten the instruction or simplify the task. [synthesis]

B. General maneuvers

B1. Reframing (restructuring)

Purpose: to change the meaning of a failed solution so that the client stops using it on their own. Reframing works on second-order reality, the meaning of events, not the events themselves. [source: Paoli 2014; Nardone & Portelli 2005, ch. 1]
Steps:
1. Identify the solution the client values: help, avoidance, control or reassurance.
2. Reveal its hidden second message or cost. The panic example: each act of help says both "I care for you" and "you can't do it alone". [source: Nardone & Portelli 2005, ch. 6]
3. Do not ask the client to stop. Ask them only to notice, each time, that the solution makes the problem worse. [source: Nardone & Portelli 2005, ch. 6]
Example language (illustrative, paraphrasing the panic reframe): "I'm not asking you to stop asking for help. I'm only asking you to notice that each time you get it, you're helping the problem stay alive."
Watch for: spontaneous reduction of the failed solution by the next session. The authors describe this approach as paradoxical, because it creates a "fear against fear": the greater fear of worsening the problem overrides the fear of facing it. Their phrase is that "every fear is limited by some greater fear". [source: Nardone & Portelli 2005, ch. 6]

B2. Logbook ("diario di bordo" / ship's log)

Purpose: officially, to monitor episodes. Strategically, to move the client's attention from the fear to the task of recording it, which tends to dampen the episode. Typically given at the end of session 1. [source: Nardone & Portelli 2005, ch. 6]
Steps:
1. Ask the client to carry a small notebook at all times.
2. For every episode, record: date, time, place, who was present, the situation, thoughts, symptoms and reactions. [source: Nardone & Portelli 2005, ch. 6]
3. Write during the episode, not before (that would be fantasy) and not after (that would be memory). Record every episode, even when it repeats. [source: Nardone & Portelli 2005, ch. 6]
4. Bring the logbook to every session. Review it for patterns, and as evidence of change.
5. Variants: for GAD, a detailed notebook of each anxious episode including internal dialogue, kept all week. [source: De la Cruz Gil 2021]
Example language (illustrative): "Write it at the very moment it's happening, as if you were taking a photo of it." The source uses a similar image of an "instant photo". [source: Nardone & Portelli 2005, ch. 6]
Watch for: clients reporting fewer or shorter episodes, or that "it didn't come" while they were ready to write. Treat this as the first change and redefine it in stage 2.

B3. How to make it worse

Purpose: to make the client aware of what maintains the problem, and to make deliberately choosing those behaviours feel absurd. It is a stage 1 prescription, used in many protocols. [source: Fronzetti Colladon citing Nardone 2009; Pietrabissa et al. 2019; Adobatto 2025]
Steps:
1. Ask the client to think, each day until the next session, about what they could do or think on purpose to make the problem worse. Ask them to write it down. [source: Fronzetti Colladon; Adobatto 2025]
2. Instruct them only to think about and list these things, not to carry them out. [synthesis]
3. Next session: review the list. It usually matches the client's attempted solutions. Reframe these as things to avoid doing.
Example language (illustrative): "Every day, ask yourself: if I wanted to make this worse, not better, what would I do or think? Write down everything that comes to mind."
Watch for: the moment of recognition ("that's what I already do"). This turns the list into a self-generated map of attempted solutions. A related logic: the client "of their own will chooses to worsen something". [source: De la Cruz Gil et al. 2025]

B4. Miracle fantasy

Purpose: to set goals and evoke a life without the problem. It is a stage 1 alternative to "how to make it worse" in the eating protocol. [source: Pietrabissa et al. 2019; Adobatto 2025 citing Vélez Colque 2019]
Steps:
1. Ask the client to imagine, in detail, that the problem has gone overnight.
2. Ask them to describe what would be different in specific behaviours and relationships.
3. Use the answers as goals, and as a source of small steps to try (see B6).
Example language (illustrative): "Imagine that tomorrow morning the problem has simply vanished. What's the first thing you'd notice you were doing differently?"
Watch for: vague answers ("I'd be happy"). Push for observable details. Note: this resembles de Shazer's miracle question, and it is not clear from the sources which tradition the CTS version comes from [uncertain].

B5. Conspiracy of silence

Purpose: to stop the family's attempted solutions of talking about, monitoring or fighting the problem, which feed it. It is a stage 1 prescription, involving family members. [source: Pietrabissa et al. 2019]
Steps:
1. With the client and family (or the client's agreement), prescribe that nobody talks about the problem or acts on it at home until the next session. [source: Pietrabissa et al. 2019]
2. Frame it as protecting the work being done in therapy. [synthesis]
3. Next session: ask each person what happened when they held back.
Example language (illustrative): "From now until we meet again, I'd like the whole family to agree not to discuss the problem at all. Leave it to the work we're doing here."
Watch for: family members who cannot hold back. This is useful evidence of their own attempted solution, so reframe it. Safety limit [synthesis]: silence must never cover medical danger or risk. Agree in advance what the family must report (for example, fainting, self-harm or suicidal talk) and to whom.

B6. Acting "as if"

Purpose: to start the change through small behaviours of the problem-free self. [source: Fronzetti Colladon]
Steps:
1. Each day, choose one small thing the client would do if the problem were already solved.
2. The client does it, and notes others' reactions. Steps grow as confidence grows.
Example language (illustrative): "Each day, pick one small thing you'd do if you were already over this, and do it as if you were."
Watch for: steps that are too large. Shrink them. [synthesis]

B7. Worst fantasy

Purpose: to reduce spontaneous fear by deliberately evoking it at set times. It is a paradoxical prescription used in the anxiety, panic and phobia protocol, often in stage 2. The image the sources give is of putting out a fire by adding wood. [source: Adobatto 2024; Fronzetti Colladon]
Steps:
1. Prepare the client: explain the task, get consent, and check for contraindications (see the safety note below).
2. Prescribe a fixed daily time and a fixed place. [source: Fronzetti Colladon] The client sets a timer for a set period, sits somewhere quiet and actively imagines their worst fantasies about the feared situation, trying to feel as bad as possible. When the time ends, they stop and return to their day. [uncertain: the CTS's exact duration and setting]
3. Next session: ask what happened. Typical reports, according to the protocol logic, are that the fear could not be produced, or faded, or turned into boredom. Redefine this as evidence that fear sought out deliberately loses its power. [synthesis based on Adobatto 2024]
Example language (illustrative): "Every day, at the same time, you'll sit down on your own for the set time and deliberately bring up your worst fears. Do all you can to feel bad. When the time is up, stop, wash your face and go back to what you were doing."
Watch for: genuine escalation into panic or dissociation. Stop the task and see Section 5. Safety note [synthesis]: this works like imaginal exposure. Do not use it with clients who have active psychosis, severe dissociation, unprocessed trauma memories as the content of the fear, current suicidality, or medical conditions where severe arousal is dangerous (for example, unassessed cardiac symptoms). Get a medical check before use for any client with cardiac-type panic symptoms.

B8. Avoid avoiding

Purpose: to block avoidance in phobic patterns. [source: Adobatto 2025 citing Pérez Ruiz & Caro Gabalda 2015]
Steps: the CTS procedure is [uncertain]. A cautious synthesis: once a reframe has made avoidance feel dangerous (B1), ask the client to notice each time they are about to avoid and to do one small thing in that situation instead of avoiding it. They log it (B2). [synthesis]
Example language (illustrative): "Each time you notice you're about to avoid, do one small thing instead of avoiding, and write it down."
Watch for: turning it into an exposure hierarchy pushed by willpower. The strategic version relies on the reframe, not on effort. [synthesis]

B9. Symptom prescription and prescribing resistance

Purpose: to unblock a symptom that the client controls through effort. Prescribing it removes its involuntary nature. Prescribing resistance to an oppositional client makes their resistance itself cooperation. These are stage 2 maneuvers. [source: De la Cruz Gil 2021; Fronzetti Colladon; Adobatto 2024]
Steps:
1. Choose the symptom or resistance.
2. Prescribe it at a set time, place or amount, with a rationale fitted to the client's logic.
3. Review the next session: either the client did it (now under control) or could not (spontaneous reduction). Both are redefined as change.
Example language (illustrative): "This week, I'd like you to deliberately set aside time to worry, at a fixed hour, and not to try to stop worrying outside that time."
Watch for: do not prescribe dangerous behaviours (self-harm, purging, substance use, risky driving). [synthesis]

B10. Writing tasks (case-specific)

Purpose: to move ruminative content onto paper at a defined time. One published case used a detailed letter written every night before bed about thoughts and feelings. [source: Adobatto 2024 citing Bartoli & De la Cruz]
Steps: set a fixed time; write in detail; do not reread the letter during the day [synthesis]; bring it to the session or not, as agreed.
Example language (illustrative): "Each night before bed, write a letter that puts down everything that went through your head that day, as fully as you can."
Watch for: if writing intensifies distress, shorten it or stop. [synthesis]

C. Protocol-specific prescriptions

Obsessive-compulsive disorder (CTS protocol, in use at Arezzo since 1990). The protocol first sorts the client's attempted solutions (avoidance, reassurance-seeking, and rituals that are preventive, propitiatory or reparatory). It then makes three distinctions: compulsions with or without a phobic basis, visible or mental rituals, and rituals built on a counted sequence or on an analogical one. These distinctions guide which technique is used. [source: Pietrabissa et al. 2016]

C1. Numerical counter-ritual ("if you do it once, do it five times")

Purpose: for rituals with a sequence. Turning a spontaneous ritual into a prescribed one, done an exact number of times, makes the ritual effortful and takes away its protective meaning. [source: Pietrabissa et al. 2016]
Steps:
1. Do not ask the client to stop the ritual. [source: Pietrabissa et al. 2016]
2. Prescribe that whenever they do the ritual once, they must repeat it exactly five times, no more and no fewer. [source: Pietrabissa et al. 2016, paraphrased]
3. Say it with emphasis, repeating the exact number.
4. Next session: review what happened. The authors report that clients often drop the ritual within days. [source: Pietrabissa et al. 2016]
Example language (illustrative): "You may do it, or not. But if you do it once, you'll do it five times exactly. Not four, not six: five."
Watch for: rituals that are harmful at five times the frequency (for example, skin damage from washing). Choose another technique for these. [synthesis]

C2. Progressive violation of the ritual

Purpose: to break the ritual sequence by deliberately changing parts of it, small changes first, up to complete violation. [source: Pietrabissa et al. 2016]
Steps: agree on one small change to the sequence (order, one element, timing); practise it for a week; increase the change at each session until the ritual is no longer done as it was. [steps: synthesis based on the source description]
Example language (illustrative): "This week, keep the ritual, but change one small part of it on purpose: the order of the last two steps."
Watch for: the client creating a new, rigid "violated" ritual. If that happens, vary the change each day. [synthesis]

C3. Postponement

Purpose: to schedule the ritual for a fixed later time instead of doing it on impulse. The authors link this mainly to compulsions that involve vomiting. [source: Pietrabissa et al. 2016]
Steps: when the urge arises, the client notes it and defers the ritual to a set later time; the delay is lengthened step by step. [steps: synthesis] Compare the interval technique in C10.
Example language (illustrative): "When the urge comes, you're allowed to do it, but not now. Do it at the time we've agreed."
Watch for: rising distress during the delay. Shorten the delay and build it up more slowly. [synthesis]

C4. Ritualising the compulsion

Purpose: to make the compulsion happen only at set times and places, then reduce it to zero. [source: Pietrabissa et al. 2016]
Steps: set fixed slots each day for the compulsion; outside those slots the client defers it to the next slot; reduce the number or length of slots across sessions. [steps: synthesis based on source]
Example language (illustrative): "From now on, checking has its appointments: three times a day, at fixed times, in one place."
Watch for: slots creeping longer. Use a timer. [synthesis]

C5. "A small disorder that maintains order"

Purpose: to loosen the need for total control in perfectionistic or contamination presentations. [source: Pietrabissa et al. 2016]
Steps: each day, the client deliberately allows one small imperfection: a little dirt left untouched, or one object out of place. The source's contamination example is accepting a small amount of dirt rather than pursuing total cleanliness. [source: Pietrabissa et al. 2016]
Example language (illustrative): "Each day, leave one small thing deliberately a little untidy. It's a small dose of disorder to protect the order."
Watch for: genuine health hazards. Keep the "disorder" harmless. [synthesis]

Bulimia nervosa and binge-eating disorder (CTS protocol). The protocol distinguishes subtypes: overweight clients who eat for pleasure; overweight clients for whom weight is a relational protection; weight-cycling clients who alternate dieting and loss of control; and the vomiting type, where pleasure lies in the binge-and-vomit ritual. Stages run roughly as follows. [source: Pietrabissa et al. 2019] The source's stage table is partly garbled, so the stage assignments are a best reading [uncertain]. Medical frame [synthesis]: treat these as psychological interventions within medical care. Get a medical assessment and ongoing monitoring (electrolytes, cardiac status, weight trend) when there is purging or significant restriction. Set no calorie, weight or exercise targets.

C6. Reframing fasting and dieting as dangerous ("fear of fasting")

Purpose: for BED and the dieting subtypes. Fasting and restriction trigger the next binge, so the client is helped to fear restricting more than bingeing. [source: Pietrabissa et al. 2019] Stage 1, combined with the conspiracy of silence (B5).
Steps: use strategic dialogue to show the cycle of restricting, bingeing, guilt and restricting again; then evoke restriction as the real enemy. [source: Pietrabissa et al. 2019]
Example language (illustrative): "So every diet you start opens the door to the next binge. The fasting isn't protecting you; it's setting the trap."
Watch for: the client hearing this as permission to binge. Pair it with the regular meals of the paradoxical diet (C7). [synthesis]

C7. Paradoxical diet

Purpose: to end the forbidden-food cycle by building favourite foods into regular meals, eaten with attention. Stage 2 for bulimia; late in treatment for BED. [source: Pietrabissa et al. 2019]
Steps:
1. Prescribe regular meals in which the client includes the foods they like most, including "forbidden" ones. Eat them at the table, slowly and with attention, without distraction. [source: Pietrabissa et al. 2019; details of meal structure: synthesis]
2. Combine this with the "if you do it once, do it five times" logic. A given food eaten outside meals must be eaten a fixed number of times, no more and no less. [source: Pietrabissa et al. 2019]
3. Review at the next session for pleasure, satiety and loss-of-control episodes.
Example language (illustrative): "At every meal, include the foods you like best, the ones you've been banning. Eat them sitting down, slowly, really tasting them."
Watch for: guilt-driven skipping of meals. Restate the reframe in C6.

C8. Planned transgressions

Purpose: stage 3. Small, deliberate "transgressions" within a balanced eating pattern are encouraged (paradoxically), so that the eating stays flexible and forbidden food loses its pull. [source: Pietrabissa et al. 2019]
Steps: agree a small, planned treat within the week's eating; the client enjoys it at the agreed time and notes the experience. [steps: synthesis]
Example language (illustrative): "This week, plan one small treat, and make sure you enjoy it without guilt."
Watch for: rigid rule-making around the treat. Keep it flexible. [synthesis]

C9. Vomiting type: "secret lover" reframe and list of foods to vomit

Purpose: stage 1 for the vomiting subtype. The binge-and-vomit cycle is reframed as a secret, pleasurable affair. A list of foods to vomit, displayed openly to the family, undermines the secrecy and private pleasure that feed the ritual. Used with the conspiracy of silence. [source: Pietrabissa et al. 2019]
Steps: use the dialogue to bring out the pleasure-and-secrecy quality of the ritual; reframe it as an affair; with consent, agree a written list displayed at home (procedure details not found in the source [uncertain]).
Example language (illustrative): "It sounds less like a punishment and more like a secret meeting you look forward to. Is that closer to how it is?"
Watch for: shame. The reframe must be delivered without judgement, and the client must consent to anything shared with the family. [synthesis]

C10. Interval technique; "perfect blowout" alternative

Purpose: stage 2 for the vomiting subtype. The interval technique progressively lengthens the gap between bingeing and vomiting, which breaks the link between them. If the client refuses, the alternative is the "perfect blowout", in which the pleasure is escalated until it turns unpleasant. [source: Pietrabissa et al. 2019] Once vomiting stops, stage 3 normalises eating with the paradoxical diet. [source: Pietrabissa et al. 2019]
Steps (interval): after a binge, the client must wait a set interval before vomiting is allowed; the interval is increased at each session. [source: Pietrabissa et al. 2019; step detail: synthesis]
Example language (illustrative): "You may still do it, but only after waiting the time we agree. Not one minute sooner."
Watch for / risk flag [synthesis]: both techniques work within a purging pattern, so they need concurrent medical monitoring. The "perfect blowout" escalates bingeing, so do not use it where there is medical instability, electrolyte disturbance, a history of gastric injury, diabetes, or pregnancy. Many clinicians will prefer to omit it altogether.

D. Consolidation and ending maneuvers

D1. Redefining the first change

Purpose: in stage 2, to turn the first small change into the expectation of more change. [source: Adobatto 2025]
Steps: ask in detail what was different; attribute the change to the client's own action; link it to the new definition of the problem; give the next prescription as the obvious next step.
Example language (illustrative): "So this week the panic tried to come twice and both times it faded while you were writing. What did you do differently that let that happen?"
Watch for: the client calling the change luck. Ask how they made the luck happen. [synthesis]

D2. Anticipating setbacks

Purpose: in stage 3, to protect gains by predicting possible setbacks and treating them as tests. [source: Adobatto 2025]
Steps: say plainly that a return of symptoms may happen; agree what the client will do (go back to the logbook or the relevant prescription); frame it as a chance to show the new skills. [steps: synthesis]
Example language (illustrative): "It's possible the old fear will knock again, to see if you're still there. If it does, you'll know exactly what to do."
Watch for: fear of relapse becoming a new attempted solution (constant self-monitoring). [synthesis]

D3. Final explanatory session and follow-up

Purpose: in stage 4, to explain the strategy that was used, credit the client with the change and return responsibility to them, then check stability. [source: Adobatto 2025; De la Cruz Gil 2021]
Steps: review the problem as it was defined; explain what each prescription did and why; underline the client's own part; arrange follow-ups at 3, 6 and 12 months. [source: Adobatto 2025 citing Nardone & Portelli 2006]
Example language (illustrative): "Now I can tell you what we were doing. Those tasks that seemed strange each turned your own reactions in a new direction, and you're the one who did them."
Watch for: the client feeling tricked. Explain the paradoxical reasoning respectfully and stress that their own effort produced the change. [synthesis]

Protocols not covered. Knowing Through Changing (ch. 6) also lists CTS protocols for dysmorphophobia, depression, blocked-performance problems, children's behaviour problems and "presumed psychosis". The specific prescriptions in these chapters are not described here [uncertain]. Consult the book directly before using the model for these presentations.

5. Handling problems

Resistance: match the maneuver to how the client collaborates. [source: Adobatto 2024, reviewing Nardone's work. Labels vary across Nardone's texts and the original typology is not drawn on here [uncertain].]

Collaborative client: use direct prescriptions and explain your reasoning openly.
Willing but unable (wants to change but cannot carry out tasks): use indirect maneuvers and evocative language, and set tasks so small that they cannot fail.
Non-collaborative or oppositional: use paradox. Prescribe the resistance, or prescribe not changing yet. Example (illustrative): "I don't think you should change anything this week. It's too soon."
Locked into their own narrative (including rigid or delusional-type beliefs): do not contradict the narrative. Shift it from inside its own logic. [source: Adobatto 2024] Where you suspect a psychotic process, assess and refer for psychiatric evaluation; this model is not a substitute for it. [synthesis]

Stuck: no change after the first prescriptions.

Do not repeat a maneuver that has failed; change it. [source: Adobatto 2025]
Go back to the strategic dialogue (A1–A4). The usual cause is a wrongly identified attempted solution, or a hidden one (for example, a relative's reassurance, or a mental ritual). [synthesis based on Pietrabissa et al. 2016, on the distinction between visible and mental rituals]
Move from direct to paradoxical prescriptions, or the other way round. [synthesis]
If two or three cycles produce no change, reconsider the formulation (comorbid depression, substance use, trauma, medical cause). In the CTS OCD study, higher baseline depression was tested as a predictor of poorer response. [source: Pietrabissa et al. 2016, hypothesis] Then consider referral or a different treatment. [synthesis]

Non-adherence: the prescription was not done. The sources do not describe a procedure for this [uncertain]. Synthesis:

Ask precisely what happened: forgot, started then stopped, did it differently, or decided not to.
Forgot or did it partly: simplify the task, attach it to a fixed daily cue, and repeat the instruction emphatically.
Did it differently: treat this as information about the client's logic, and if the variant worked, adopt it.
Refused: treat as opposition and switch to paradox, for example: "Perhaps you're right not to do it yet."
Never shame the client. A failed task is information about the fit between task and client, not a failing in the client.

Overwhelm during a paradoxical or exposure-like task (worst fantasy, how to make it worse). [synthesis throughout]

Before giving these tasks, screen for: psychosis, severe dissociation, active suicidality, untreated PTSD where the feared content is a trauma memory, cardiac or other medical conditions that make high arousal unsafe, and current substance misuse.
Give a stop rule: the client may end the task at any point and use grounding (naming objects in the room, cold water, slow breathing, feet on the floor). They log what happened.
If panic or dissociation escalates in session, stop the procedure. Ground the client and stay present until they are oriented. Do not try to process the content further that day.
Next session, reduce the duration or change to a gentler maneuver, such as the logbook alone or the help reframe.
Never use these tasks to recover or probe trauma memories.

Ruptures (the client feels manipulated, tricked or not taken seriously). [synthesis]

Paradoxical prescriptions can feel like irony or blame. If the client reacts with anger or withdrawal, acknowledge the reaction directly. Explain the reasoning in plain language: the task is meant to change how the problem behaves, not to test or mock them.
Give the client a choice of tasks.
Tell clients at the outset that some tasks will seem odd, and that you will explain everything by the end of treatment. This fits the final explanatory session (D3) and keeps informed consent intact.
Never prescribe something you would be uncomfortable explaining to the client later.

Dependence on the therapist. The help reframe (B1) applies to therapy too: reassurance from the therapist can become a new attempted solution. Limit phone contact between sessions, and keep sessions spaced (the CTS research protocols use fortnightly sessions). [source: Pietrabissa et al. 2016; 2019 on spacing; reframe extension: synthesis]

Family undermines the work (continues reassuring, monitoring, or talking about the problem). Prescribe or renew the conspiracy of silence (B5), and reframe the family's help in the same terms as B1. [source: Pietrabissa et al. 2019; Nardone & Portelli 2005, ch. 6] Invite a relative to one session if needed. [synthesis]

Relapse after improvement. Treat it as the predicted test (D2). Go back to the last effective prescription, and check whether an old attempted solution has returned. [synthesis based on Adobatto 2025]

Risk. [synthesis] Brief strategic work does not replace standard risk assessment. Assess suicidal ideation and self-harm at intake and whenever mood drops. Use current practice for safety planning, including lethal-means counselling (safe storage, removal). Never set a paradoxical or "make it worse" task that touches self-harm, purging, restriction or other dangerous behaviour. In eating disorders, follow medical-risk guidance and arrange monitoring with the medical team.

Modality-specific pitfalls. [synthesis]

Using protocols mechanically: the CTS stresses that protocols correct themselves according to the client's response. Read each session's result before giving the next task.
Over-explaining: rational explanation in the early stages can weaken the evocative effect. Keep explanation for stage 4.
Questions that lead too strongly: the illusion-of-alternatives format can put words in the client's mouth. Always allow a third answer and check paraphrases honestly.
Using the model outside its scope: complex trauma, severe personality disorder, active psychosis and medically unstable eating disorders need specialist, phase-based care. Use strategic techniques only as adjuncts within that care.

Sources

Sources:

Further reading (not drawn on, or only partly):

Nardone G, Watzlawick P (1993). The Art of Change: Strategic Therapy and Hypnotherapy without Trance. Jossey-Bass.
Nardone G, Watzlawick P (2005). Brief Strategic Therapy: Philosophy, Techniques, and Research. Jason Aronson.
Nardone G, Portelli C (2005). Knowing Through Changing: The Evolution of Brief Strategic Therapy. Crown House.
Nardone G, Salvini A (2007; Routledge English edition 2019). The Strategic Dialogue: Rendering the Diagnostic Interview a Real Therapeutic Intervention.
Nardone G (2009). Problem Solving Strategico da tasca. Ponte alle Grazie.
Nardone G, Balbi E (2008). Solcare il mare all'insaputa del cielo. Ponte alle Grazie.

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