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Multimodal Therapy: A Primer By Arnold A. Lazarus, Ph.D., ABPP Distinguished Professor Emeritus of Psychology Rutgers University, Piscataway, NJ .

Table of Contents Introduction 1. Theoretical Bases 2. Multimodal Assessment And Treatment 3. Clinical Indications And Exclusions 4. Empirical Support For MMT Summary References Glossary

Introduction It appears that most theoreticians and clinicians are now in favor of using a broad-spectrum approach to treating patients. For example, there is a current trend toward the use of holistic treatments that not only consider intra-individual, interpersonal and systemic factors, but also argue for the inclusion of a separate transpersonal (i.e., spiritual) dimension. Multimodal therapy (MMT) strives to combine a broad and interactive set of systematic strategies, and offers particular assessment tactics that enhance diagnosis, promote a focused range of effective interventions, and improve treatment outcomes. As a psychotherapeutic approach, the theoretical underpinnings of MMT rest on a broad-based social and cognitive learning theory, while also drawing on effective techniques from many additional disciplines - without necessarily subscribing to their particular theories (i.e., it espouses technical eclecticism). MMT is based on the assumption that most psychological problems are multifaceted, multi-determined and multilayered, and that comprehensive therapy calls for a careful assessment of seven dimensions or "modalities" in which individuals operate Behavior, Affect, Sensation, Imagery, Cognition, Interpersonal relationships and Biological processes. Given that the most common biological intervention is the use of psychotropic drugs, the first letters from the seven modalities can be combined to produce the convenient acronym "BASIC I.D." - although it must be remembered that the "D" modality actually represents a range of both medical and biological factors. MMT's detailed assessment approach was developed after clinical follow-ups showed a fairly high relapse rate in patients who received "narrow band" rather than "broad-spectrum" treatment (Lazarus, 1989). While many systems tend to assess the usual "ABC" variables (i.e., Affect,

Behavior, and Cognition), most overlook or omit significant Sensory, Imagery, Interpersonal and Biological issues. As such, untreated excesses and deficits in these areas of human functioning may leave patients vulnerable to backsliding. In other words, therapeutic breadth is emphasized. Over many years, my follow-ups have revealed more durable treatment outcomes when the entire BASIC I.D. is assessed, and when significant problems in each modality are remedied (Lazarus 1989; 1997, 2005, 2005b). MMT is, however, in a sense a misnomer, because there exists no single treatment method that is totally distinctive to this approach. Instead, MMT offers a set of distinct assessment procedures that facilitate treatment outcome by shedding light on the interactive processes at play in patients' problems, and by pinpointing the selection of appropriate techniques and their best mode of implementation. It should be emphasized that in MMT, one endeavors to use, whenever possible and applicable, empirically supported treatments (such as those described by Chambless et al., 1998). Thus, practitioners of MMT are typically at the cutting edge of the field, drawing on scientific and clinical findings from all credible sources. This technically eclectic outlook is central and pivotal to MMT, and will be described in greater detail in the following section. At this point, however, it is important to stress that the MMT approach sees theoretical eclecticism, or any attempt to integrate different theories in the hopes of producing a more robust technique, as futile and misguided (Lazarus, 2005b). A systematic, technical eclecticism, on the other hand, opens many avenues that can enhance therapeutic understanding and effectiveness (Lazarus, Beutler & Norcross, 1992). The emphasis on techniques by no means ignores the importance of the alliance and rapport that must develop between clients and therapists for the procedures to be effective. The therapeutic relationship is regarded as the soil that enables techniques to take root.

1. Theoretical Bases A. Social Learning Theory

As mentioned in the introduction, MMT is based on the principles and procedures of experimental psychology, most notably social and cognitive learning theory. In essence, social learning theory states that all behaviors (normal and abnormal) are created, maintained, and modified through environmental events. While initial behavioral theories rested on animal analogues and were decidedly mechanistic (offering rather simplistic analyses of stimulusresponse contingencies), the advent of what is now termed cognitive-behavior therapy (CBT) is anchored to a much more sophisticated foundation. CBT is based on the finding that cognitive processes determine the influence of external events, and can in turn be affected by the social and environmental consequences of behavior. As such, the main focus is on the constant reciprocity between personal actions and environmental consequences. Social learning theory also recognizes that association plays a key role in all learning processes. In other words, events that occur simultaneously or in quick succession are likely to be

connected. An association may be said to exist when responses evoked by one set of stimuli are similar to those elicited by other stimuli. The basic social learning triad is made up of classical (respondent) conditioning, operant (instrumental conditioning), and modeling and other vicarious processes. Finally, also added to the foregoing is the idiosyncratic use of language, expectancies, selective attention, goals and performance standards, as well as the impact of the individual's numerous values, attitudes, and beliefs. An individual's thoughts will determine which stimuli are noticed, how much they are valued, and how long they are remembered. While it is beyond the scope of this paper to do justice to all of the nuances of social learning theory, it is my hope that its level of sophistication and experimentally-based outlook can be appreciated. B. Technical Eclecticism

An essential concept in MMT is that of technical eclecticism. While there are still many school adherents who refuse to look beyond the boundaries of their own theories for ideas and methods that may enhance their clinical acumen, an increasing number of therapists have become aware that no one theory can possibly provide all the answers. Therefore they are willing to incorporate different methods and procedures into their practice. It should be noted, however, that there are several alternate ways in which different methods may be combined, including: (a) utilizing several techniques within a given approach (e.g., exposure, response prevention, and participant modeling from a behavioral perspective), (b) combining techniques from different disciplines (especially when confronted by a seemingly intractable patient or problem), (c) using medication in conjunction with psychosocial therapies, (d) treating certain clients with a combination of individual, family and group therapy, or (e) looking to other disciplines (e.g., social work in the case of vocational rehabilitation). As I see it, there are three principal routes to integration: (1) technical eclecticism, (2) theoretical integration, and (3) common factors. It must be emphasized that those who attempt to meld different or even disparate theories (theoretical integrationists), differ significantly from those who remain theoretically consistent but use diverse techniques (technical eclectics). In essence, there appears to be no data to support the notion that a blend of different theories has resulted in a more robust therapeutic technique or has led to synergistic practice effects. In addition, those who dwell on common ingredients shared by different therapies (e.g., self-efficacy, enhanced morale, or corrective emotional experiences) are apt to ignore crucial differences while emphasizing essential similarities. It cannot be overstated that the effectiveness of specific techniques may have absolutely no connection to the theories that spawned them. Techniques may, in fact, prove effective for reasons that do not remotely relate to the theoretical ideas that gave birth to them. This is not meant to imply that techniques operate or function in a vacuum. Theories are needed to explain or account for various phenomena and to try to make objective sense out of bewildering observations and assertions. It is precisely because social learning and cognitive theories are experimentally grounded that MMT embraces them over any of the other postulates in the marketplace. However, clinically it makes sense to select seemingly effective techniques from any discipline without necessarily subscribing to the theories that generated them.

It also cannot be overstated that in MMT, the selection and development of specific techniques are not at all capricious. On the contrary, the position of MMT is that eclecticism is warranted only when: (a) empirically supported treatments do not exist for a particular disorder, or (b) empirically supported treatments are not achieving the desired results. Thus, when empirically supported treatments, despite proper implementation, fail to be helpful, one may resort to less authenticated procedures or endeavor to develop new strategies. In fact, I would assert that a practitioner's clinical effectiveness is directly proportional to the range of effective tactics, strategies and methods that are at his or her disposal. Nevertheless, it must be emphasized that the rag-tag combining of techniques from anywhere and/or everywhere without a sound rationale will likely only result in syncretistic confusion. As such, arbitrary blends of different techniques are to be decried. 2. Multimodal Assessment And Treatment A. The BASIC I.D.

Whereas many of the psychotherapeutic approaches used today are trimodal (addressing the familiar affect, cognition and behavior or "ABC"), the outcomes of several follow-up inquiries have pointed to the importance of therapeutic breadth if treatment gains were to be maintained. MMT addresses this problem by calling the clinician's attention to no less than seven discrete but interactive modalities. At base, we are all biological organisms (biochemical/neurophysiological entities), who behave (act and react), emote (experience affectiveresponses), sense (respond to tactile, olfactory, gustatory, visual and auditory stimuli), imagine (conjure up sights and sounds and other events in our mind's eye), think (hold beliefs, opinions, values and attitudes), and interact (enjoy, tolerate, or suffer various interpersonal relationships). Thus, MMT provides clinicians with a comprehensive assessment template. By separating sensations from emotions, distinguishing between images and cognitions, emphasizing both intraindividual and interpersonal behaviors, and underscoring the biological substrate, MMT is most far-reaching. In addition, as was mentioned above, by referring to these seven modalities as Behavior, Affect, Sensation, Imagery, Cognition, Interpersonal, and Drugs/Biology, the interactive modalities can be easily recalled by taking the first letter of each one to form the acronym "BASIC I.D." Using this assessment template will help to ensure that the clinician leaves no stone unturned. Students and colleagues frequently inquire as to whether particular modalities are more significant (and thus, should be more heavily weighted) than others. My typical response is that, whereas for thoroughness all seven modalities require careful attention, it is the biological and interpersonal modalities that are the most significant. Clearly, the biological modality wields a profound influence on all the other modalities: unpleasant sensory reactions can signal a host of medical illnesses; excessive emotional reactions (anxiety, depression and rage) may all have biological determinants; faulty thinking, and images of gloom, doom and terror may derive entirely from chemical imbalances; and troublesome personal and interpersonal behaviors may stem from various somatic reactions ranging from toxins (e.g., drugs or alcohol) to intracranial lesions. It is, of course, essential when any doubts arise about the probable involvement of

biological factors, to have them fully investigated by a qualified professional. Conversely, a person who has no problematic medical/physical problems and enjoys warm, meaningful and loving relationships is apt to find life personally and interpersonally fulfilling. Hence perhaps it is best to picture the biological modality serving as the base of a pyramid that contains each of the modalities, with the interpersonal modality at the apex. It must be emphasized, however, that the seven modalities are by no means static or linear, but instead exist in a state of reciprocal transaction. How does a clinician assess each of these modalities? Typically, through the use of a range of questions. For example, to assess the client's behavior, the clinician may ask: "What is this individual doing that is getting in the way of his or her happiness or personal fulfillment (selfdefeating actions, maladaptive behaviors)?" Or perhaps, "What does the client need to increase and decrease?" Or even, "What should he/she stop doing and start doing?" To assess the client's affect the clinician may ask: "What emotions (affective reactions) are predominant?" Or, "Are we dealing with anger, anxiety, depression, or combinations thereof, and if so, to what extent (e.g., irritation versus rage; sadness versus profound melancholy)?" The clinician may ask, "What appears to generate these negative affects - certain cognitions, images, interpersonal conflicts?" And, "How does the person respond (behave) when feeling a certain way?" Remember, however, that in addition to assessing each modality separately, it is also important to look for interactive processes that occur between and among the modalities (i.e., the impact that various behaviors have on the client's affect and vice versa). To assess the client's sensations, the clinician may ask: "Are there any specific sensory complaints (e.g., tension, chronic pain, tremors)?" Also, "What positive sensations (e.g., visual, auditory, tactile, olfactory and gustatory delights) does the person report?" Or, staying with the notion that one must also assess interactions among modalities, the clinician may ask, "What feelings, thoughts and behaviors are connected to these negative sensations?" It should be noted that assessment of this modality should also include the individual as a sensual and sexual being and, when called for, treatment interventions should be aimed at the enhancement or cultivation of erotic pleasure. To assess the client's imagery, the clinician may ask: "What fantasies and images are predominant?" "What is this client's self-image?" The clinician may also assess for specific success or failure images that the client holds, and will certainly want to ask whether the client experiences any negative or intrusive images (e.g., flashbacks to unhappy or traumatic experiences). Of course, as with the other modalities, the clinician will also want to assess how the client's images are connected to ongoing cognitions, behaviors, affective reactions, etc. To assess the client's cognitions, the clinician may ask: "Can we determine the client's main attitudes, values, beliefs and opinions?" And, "Are there any definite dysfunctional beliefs or irrational ideas?" Or perhaps the clinician will assess the client's predominant "should statements" or try to detect any problematic automatic thoughts that undermine the client's functioning.

To assess the client's interpersonal functioning, the clinician may ask: "Who are the significant others in this client's life?" Or, "What does this client want, desire, expect and receive from others, and what does he or she, in turn, give to and do for them? The clinician may also ask, "What relationships give this particular client pleasures and pains?" Finally, to assess the client's biological dimension, the clinician may ask: "Is this client biologically healthy and health conscious?" "Does he or she have any medical complaints or concerns?" And, "What relevant details pertain to diet, weight, sleep, exercise, and alcohol and drug use?" While a client presenting for treatment may use one of the seven modalities as his or her entry point (e.g., behavior: "It's my compulsive habits that are getting to me" or interpersonal: "My wife and are not getting along"), it is more typical for people to enter into treatment with problems in two or more of the modalities (e.g., "I have all sorts of aches and pains that my doctor tells me are due to tension, I worry too much, and I feel frustrated a lot of the time. I am also very angry with my father"). Initially then, it is usually advisable to engage the client by focusing on the presenting issues, modalities, and/or areas of concern that he or she presents. To deflect the emphasis too soon onto other matters that may seem more important is only inclined to make the patient feel invalidated. Once rapport has been established, however, it is usually easy to shift to more significant problems. It should be noted, however, that before fleshing out the details, any competent clinician would likely begin by addressing and investigating the presenting issues (e.g., "Please tell me more about the aches and pains you are experiencing." "Do you feel tense in any specific areas of your body?" "You mentioned worries and feelings of frustration. Can you please elaborate on them for me?" "What are some of the specific clash points between you and your father?"). The multimodal therapist will carefully note the specific modalities across the BASIC I.D. that are being discussed, and which ones are omitted or glossed over. The latter (i.e., the areas that are overlooked or neglected) can then be addressed, and often yield important clinical information. Thus, by thinking in BASIC I.D. terms, a clinician or counselor is apt to leave fewer important avenues unexplored. B. Second Order BASIC I.D.

Whereas the initial BASIC I.D. is used to translate vague, general, or diffuse problems (e.g., I feel depressed or anxious) into specific, discrete, and interactive difficulties, which can then be addressed with various techniques (preferably those with empirical backing), Second Order BASIC I.D. assessments are typically saved for when therapy falters. Every clinician, regardless of his or her level of experience, reaches treatment impasses. When this occurs, a more detailed inquiry into the associated behaviors, affective responses, sensory reactions, images, cognitions, interpersonal factors, and possible biological considerations may help to shed some light on the situation. For example, an unassertive person who is not responding to the usual social skills and assertiveness training methods, may be asked to spell out the specific consequences that an

assertive way of living might have on his or her behaviors, affective reactions, sensory responses, imagery, and cognitive processes. Of course, interpersonal repercussions would also be examined and, if relevant, biological factors would be determined (e.g., "If I start expressing my feelings I may become less anxious and require fewer tranquilizers"). Quite often, this procedure can bring to light reasons behind such factors as noncompliance and poor progress. A case in point was a man who was not responding to role-playing and other assertiveness training procedures. Upon traversing a Second Order BASIC I.D. assessment, he revealed a central cognitive schemata to the effect that he was not entitled to be confident, positive, and in better control of his life, because this would only show up his profoundly reticent and inadequate father. Consequently, the treatment focus shifted to a thorough examination of his entitlements. C. Bridging

Bridging (a strategy that is probably employed by most effective therapists) can readily be taugh...