Multimodal Therapy In Clinical Psychology Research Paper

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The outcomes of several follow-up inquiries pointed to the importance of breadth if treatment gains were to be maintained, and led to the development of the multimodal approach. Emphasis was placed on the fact that at base, we are biological organisms (neurophysiological/biochemical entities) who behave (act and react), emote (experience affective responses), sense (respond to tactile, olfactory, gustatory, visual, and auditory stimuli), imagine (conjure up sights, sounds, and other events in our mind’s eye), think (entertain beliefs, opinions, values, and attitudes), and interact with one another (enjoy, tolerate, or suffer various interpersonal relationships). By referring to these seven discrete but interactive dimensions or modalities as Behavior, Affect, Sensation, Imagery, Cognition, Interpersonal, Drugs/Biologicals, the convenient acronym BASIC I.D. emerges from the first letter of each one.

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The BASIC I.D. or multimodal framework rests on a broad social and cognitive learning theory (Bandura 1977, 1986, Rotter 1954) because its tenets are open to verification or disproof. Instead of postulating putative complexes and unconscious forces, social learning theory posits testable developmental factors (e.g., modeling, observational, and enactive learning, the acquisition of expectancies, operant, and respondent conditioning, and various self-regulatory mechanisms). While drawing on effective methods from any discipline, the multimodal therapist does not embrace divergent theories but remains consistently within social-cognitive learning theory. The virtues of technical eclecticism (Lazarus 1992, Lazarus et al. 1992) vs. the dangers of theoretical integration have been emphasized (e.g., Lazarus 1995, Lazarus and Beulter 1993). The major criticism of theoretical integration is that it inevitably tries to blend incompatible notions and only breeds confusion.

1. The Holistic And Comprehensive Nature Of The Multimodal Orientation

The polar opposite of the multimodal approach is the Rogerian or Person-centered orientation that is entirely conversational and virtually unimodal. While the relationship between therapist and client is highly significant and sometimes ‘necessary and sufficient,’ in most instances, the doctor-patient relationship is but the soil that enables the techniques to take root. A good relationship, adequate rapport, a constructive working alliance are ‘usually necessary but often insufficient’ (Fay and Lazarus 1993).

Many psychotherapeutic approaches are trimodal, addressing affect, behavior, and cognition—ABC. The multimodal approach provides clinicians with a comprehensive template. By separating sensations from emotions, distinguishing between images and cognitions, emphasizing both intraindividual and interpersonal behaviors, and underscoring the biological substrate, the multimodal orientation is most farreaching. By assessing a client’s BASIC I.D. one endeavors to ‘leave no stone unturned.’

The elements of a thorough assessment involve the following range of questions:

(a) What is this individual doing that is getting in the way of his or her happiness or personal fulfillment (self-defeating actions, maladaptive behaviors)? What does the client need to increase and decrease? What should he/she stop doing and start doing? (B)

(b) What emotions (affective reactions) are predominant? Are we dealing with anger, anxiety, depression, combinations thereof, and to what extent (e.g., irritation vs. rage; sadness vs. profound melancholy)? What appears to generate these negative affects—certain cognitions, images, interpersonal conflicts? And how does the person respond (behave) when feeling a certain way? It is important to look for interactive processes—what impact does various behaviors have on the person’s affect and vice versa? How does this influence each of the other modalities? (A)

(c) Are there specific sensory complaints (e.g., tension, chronic pain, tremors)? What feelings, thoughts and behaviors are connected to these negative sensations? What positive sensations (e.g., visual, auditory, tactile, olfactory, and gustatory delights) does the person report? This includes the individual as a sensual and sexual being. When called for, the enhancement or cultivation of erotic pleasure is a viable therapeutic goal. (S)

(d) What fantasies and images are predominant? What is the person’s ‘self-image?’ Are there specific success or failure images? Are there negative or intrusive images (e.g., flashbacks to unhappy or traumatic experiences)? And how are these images connected to ongoing cognitions, behaviors, affective reactions, etc.? (I)

(e) Can we determine the individual’s main attitudes, values, beliefs, and opinions? What are this person’s predominant shoulds, oughts, and musts? Are there any definite dysfunctional beliefs or irrational ideas? Can we detect any untoward automatic thoughts that undermine his or her functioning? (C)

(f ) Interpersonally, who are the significant others in this individual’s life? What does he or she want, desire, expect, and receive from them, and what does he or she, in turn, give to and do for them? What relationships give him/her particular pleasures and pains? (I)

(g) Is this person biologically healthy and health conscious? Does he or she have any medical complaints or concerns? What relevant details pertain to diet, weight, sleep, exercise, alcohol and drug use? (D)

The foregoing are some of the main issues that multimodal clinicians traverse while assessing the client’s BASIC I.D. A more comprehensive problem identification sequence is derived from asking most clients to complete the Multimodal Life History Inventory (Lazarus and Lazarus 1991). The Inventory is useful for speeding up routine history taking and readily provides the therapist with a BASIC I.D. analysis. Most psychiatric outpatients who are reason- ably literate will comply.

2. Placing The BASIC I.D. In Perspective

In multimodal assessment, the BASIC I.D. serves as a template to remind us to examine each of the seven modalities and their interactive effects. It implies that we are social beings who move, feel, sense, imagine, and think, and that at base we are biochemical-neurophysiological entities. The seven modalities are by no means static or linear but exist in a state of reciprocal transaction.

Why bother to work multimodally—why involve the entire BASIC I.D. when feasible? Follow-up studies that have been conducted since 1973 consistently have suggested that durable outcomes are in direct proportion to the number of modalities deliberately traversed. Although there is obviously a point of diminishing returns, it is a multimodal maxim that the more someone learns in therapy, the less likely they are to relapse. In this connection, circa 1970, it became apparent that lacunae or gaps in people’s coping responses were responsible for many relapses. This occurred even after they had been in various (nonmultimodal) therapies, often for years on end. It is important to emphasize that it takes up very little extra time to assess and ameliorate the most salient problems across a patient’s BASIC I.D. Follow-up indicates that this ensures far more compelling and durable results (Lazarus 2000). Brief multimodal therapy has been fully explicated (Lazarus 1997). MMT takes Paul’s (1967, p. 111) mandate very seriously: ‘WHAT treatment, by WHOM, is most effective for THIS individual with THAT specific problem and under WHICH set of circumstances? But in addition to techniques of choice, the multimodal clinician tries to be an authentic chameleon who also asks about relationships of choice. Decisions regarding different relationship stances or styles include when and how to be directive, supportive, reflective, cold, warm, tepid, gentle, tender, tough, earthy, chummy, casual, informal, or formal.

3. Some Specific Features Of Multimodal Therapy

3.1 Bridging

A strategy that is probably employed by most effective therapists can readily be taught to novices via the BASIC I.D. format. It has been referred to as Bridging. Let’s say a therapist is interested in a client’s emotional responses to an event. ‘How did you feel when your parents showered attention on your brother but left you out?’ Instead of discussing their feelings, the client responds with defensive and irrelevant intellectualizations. ‘My parents had strange priorities and even as a kid I used to question their judgment. Their appraisal of my brother’s needs was way off—they saw him as deficient whereas he was quite satisfied with himself.’ Additional probes into their feelings only yield similar abstractions. It is often counterproductive to confront the client and point out that they are evading the question and seem reluctant to face their true feelings. In situations of this kind, bridging is usually effective. First, the therapist deliberately tunes into the client’s preferred modality—in the case, the cognitive domain. Thus, the therapist explores the cognitive content. ‘So you see it as a consequence involving judgments and priorities. Please tell me more.’ In this way, after perhaps a 5–10 minute discourse, the therapist endeavors to branch off into other directions that seem more productive. ‘Tell me, while we have been discussing these matters, have you noticed any sensations anywhere in your body?’ This sudden switch from Cognition to Sensation may begin to elicit more pertinent information (given the assumption that in this instance, Sensory inputs are probably less threatening than Affective material). The client may refer to some sensations of tension or bodily discomfort at which point the therapist may ask him or her to focus on them. ‘Will you please close your eyes, and now feel that neck tension. (Pause). Now relax deeply for a few moments, breathe easily and gently, in and out, just letting yourself feel calm and peaceful.’ The feelings of tension, their associated images, and cognitions may then be examined. One may then venture to bridge into Affect. ‘Beneath the sensations, can you find any strong feelings or emotions? Perhaps they are lurking in the background.’ At this juncture it is not unusual for clients to give voice to their feelings. ‘I feel a lot of anger and sadness.’ By starting where the client is and then bridging into a different modality, most clients then seem to be willing to traverse the more emotionally charged areas they had been avoiding.

There are two other specific MMT procedures that should be mentioned. The first is called ‘Tracking the ‘‘Firing Order’’ of Specific Modalities,’ and the other is ‘Second-order BASIC I.D. Assessments.’

3.2 Tracking The ‘Firing Order’

A fairly reliable pattern may be discerned behind the way in which people generate negative affect. Some dwell first on unpleasant sensations (palpitations, shortness of breath, tremors), followed by aversive images (pictures of disastrous events), to which they attach negative cognitions (ideas about catastrophic illness), leading to maladaptive behavior (withdrawal and avoidance). This S-I-C-B firing order (Sensation, Imagery, Cognition, Behavior) may require a different treatment strategy from that employed with say a C-IS-B sequence, a I-C-B-S, or yet a different firing order. Clinical findings suggest that it is often best to apply treatment techniques in accordance with a client’s specific chain reaction. A rapid way of determining someone’s firing order is to have them in an altered state of consciousness—deeply relaxed with eyes closed—contemplating untoward events and then describing the sequence of feelings, thoughts, and other reactions.

3.3 Second-Order BASIC I.D. Assessments

The initial Modality Profile (BASIC I.D. Chart) translates vague, general, or diffuse problems (e.g., depression, unhappiness, and anxiety) into specific, discrete, and interactive difficulties. Techniques—preferably those with empirical backing—are selected to counter the various problems. Nevertheless, treatment impasses arise, and when this occurs, a more detailed inquiry into associated behaviors, affective responses, sensory reactions, images, cognitions, interpersonal factors, and possible biological considerations may shed light on the situation. This recursive application of the BASIC I.D. to itself adds depth and detail to the macroscopic overview afforded by the initial Modality Profile. Thus, a second-order assessment with a client who was not responding to antidepressants and a combination of cognitive-behavioral procedures revealed a central cognitive schema ‘I am not entitled to be happy’ that had eluded all other avenues of inquiry. Therapy was then aimed directly at addressing this maladaptive cognition.

4. Research Findings

Williams (1988) in a carefully controlled outcome study, compared multimodal assessment and treatment with less integrative approaches in helping children with learning disabilities. Clear data emerged in support of the multimodal procedures. Kwee (1984) conducted a treatment outcome study on 84 hospitalized patients suffering from obsessive-compulsive disorders or phobias, 90 percent of whom had received prior treatment without success, and 70 percent of whom had suffered from their disorders for more than 4 years. Implementing multimodal treatment regimes resulted in substantial recoveries and durable 9-month follow-ups. This has been confirmed and amplified by Kwee and Kwee-Taams (1994). Recently, the vast literature on treatment regimens, be they journal articles or entire books, has accentuated multimodal therapy—although the authors often label their work multidimensional, multimethod, or multifactorial.

Herman (e.g., 1992, 1994) has conducted a good deal of research into the reliability and validity of various multimodal assessment instruments and their applications to several areas and clinical conditions.

Nevertheless, MMT is so broad based, so flexible, and so personalistic that tightly controlled outcome research is virtually impossible. There is, at best, suggestive evidence, rather than hard data, to confirm the clinical impression that covering the BASIC I.D. enhances outcomes and follow-ups. It should be understood that MMT endeavors first and foremost to apply empirically supported methods whenever feasible (most of which are drawn from the field of cognitive behavior therapy (CBT), because careful studies have found it to be one of the very few orientations with well-established empirically supported treatments).

5. Concluding Comment

The field of CBT—from which MMT draws the vast majority of its techniques and procedures—has grown increasingly broad-based over the past two decades. Many of the methods advocated by MMT in the 1970s that were viewed askance by behaviorally oriented theorists and practitioners are now mainstream methods within a cognitive-behavioral framework. These include various methods of cognitive restructuring, mental imagery, and sensory awareness techniques. The entire field of psychological treatment seems to have shifted away from the exclusive focus on intrapsychic phenomena that dominated the profession during the 1950s, toward a perspective that emphasizes breadth.

Perhaps MMT has played a role in facilitating what might become a twenty-first century direction in psychological treatment. The results of the Delphi poll (Norcross et al. 1992) portend systematic eclecticism’s continued domination of the field. One may predict that treatments of choice for selected clinical disorders will become standard practice, and that psychological therapies will be matched increasingly to client variables beyond diagnostic labels. Indeed, diagnostic categories seldom have relevance for the specific, moment-to-moment decisions made by practitioners. It is probable that programatic goals will be designed on the basis of a guiding theoretical definition of what is clinically relevant and meaningful. In the most general terms, one can predict confidently that the twenty-first century will witness unimodal schools of psychological thought replaced by multimodal, multifaceted, and multidimensional perspectives.


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