Chapter 13 Although psychoanalysis occupied center stage and reigned supreme during the 1950s and 1960s, many different schools of psychotherapy arose, and the pundits of each claimed that their own methods were superior to all others. Yet more and more clinicians began to realize that no single approach could have all the answers and that various ideas from divergent sources each potentially offered something of value. But how could the scientifically minded student or practitioner determine which of the manifold theories to select, and what strategies and techniques to apply? Some complained bitterly that they were confused by the conflicting theories espoused by the protagonists within these different domains. A statement by Perry London (1964) provided me with a way out of this morass and became the underpinning of my entire approach to psychotherapy: “However interesting, plausible, and appealing a theory may be, it is techniques, not theories, that are actually used on people. Study of the effects of psychotherapy, therefore, is always the study of the effectiveness of techniques” (p. 33). Inspired by this thought, I gathered effective techniques from many orientations. This culminated in a brief note, “In Support of Technical Eclecticism,” (Lazarus, 1967) that recommended culling effective techniques from many orientations without subscribing to the theories that spawned them. I argued that to combine different theories in the hopes of creating more robust methods would only furnish a mélange of diverse and incompatible notions. Technical (not theoretical) eclecticism would permit one to borrow, import, and apply a broad range of potent strategies. Subsequently, I contributed chapters to books on eclectic psychotherapy and wrote at length about the pros of technical eclecticism and the cons of theoretical integration (Lazarus, 1986, 1987, 1989, 1992, 1995, 1996; Lazarus & Beutler, 1993; Lazarus, Beutler, & Norcross, 1992; Lazarus & Lazarus, 1987). I am not in favor of theoretical integration. Technical eclecticism (TE) is an integral approach within the overall framework of psychotherapy integration. In addition to TE, there are common factors proponents who search for aspects that are present in most, if not all, approaches to therapy. Then there is theoretical integration (which attempts to integrate theoretical concepts from difficult approaches and which, as already emphasized, I regard as most unfortunate). There are those that favor what they have termed assimilative integration, which I see as a needless attempt to form a new approach that merely muddies the water. Norcross and Goldfried (2005) and Stricker and Gold (2006) provide detailed accounts of these different integrative approaches. As I have underscored in Lazarus (2005a), psychotherapy integration has outlived its usefulness. The narrow and self-limiting consequences of adhering to a particular school of thought are now self-evident to most. It seems that the current emphasis in enlightened circles has turned to empirically supported methods and the use of manuals in psychotherapy research and practice. I predict that these will remain key elements throughout much of the twenty-first century. Technical eclecticism fits in well with the overall trajectory I have just outlined. But it is important to understand how inadvisable it is to employ techniques in a disembodied manner detached from unifying principles and a theory of behavior. Consequently, I chose social and cognitive theories as my anchor (see Bandura, 1986, 2001) because they are data based and deal only with concepts and ideas that are open to verification or disproof. When the outcomes of several follow-up inquiries pointed to the importance of breadth if treatment gains were to be maintained (the more clients learned in therapy, the less likely they were to relapse), this led to the development of the multimodal approach (see Lazarus, 1997, 2000, 2005b). Emphasis was placed on the fact that at base, we are biological organisms (neurophysiological/biochemical entities) who behave (act and react), emote (experience and display 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). If we refer to the Neurophysiological/Biochemical base as Drugs/Biology (as most psychiatric interventions focus on appropriate medications when indicated) we have seven discrete but interactive dimensions or modalities: Behavior, Affect, Sensation, Imagery, Cognition, Interpersonal, Drugs/Biology, the convenient acronym BASIC ID emerges from the first letter of each one. While drawing on effective methods from any orientation, the multimodal therapist does not embrace divergent theories but remains consistently within social cognitive theory. Larry Beutler has developed an elaborate and well-structured orientation based on technical eclecticism that he calls “Systematic Treatment Selection and Prescriptive Psychotherapy” (see Beutler, Consoli, & Lane, 2005). It will be clinically enriching to gain an understanding of both Beutler’s prescriptive psychotherapy and my multimodal therapy. There is a great deal of overlap between systematic prescriptive psychotherapy (SPP) and multimodal therapy (MMT). Perhaps the main difference between them is that MMT stresses the need to provide broad-spectrum treatment strategies, whereas SPP focuses more on matching different treatments to different people. Beutler and his colleagues have been identifying patient qualities that predict differential effectiveness. The well-known maxim, “different folks need different strokes” exemplifies the core of SPP’s search for treatments of choice based less on the MMT focus on specific treatments for specific problems, but on appropriate and effective techniques for specific people. Beutler has found that the therapist’s level of directiveness must usually be matched to the client’s degree of resistance. Thus, there are data to support the finding that resistant clients benefit more from self-control methods and minimal therapist directiveness, whereas clients with low resistance benefit more from therapist directiveness and explicit guidance. Although MMT stresses the need for flexible therapist styles, SPP spells out very clearly, in particular instances, exactly what is likely to prove effective. Thus, according to Beutler, patients with externalizing or impulsive styles are apt to respond favorably to symptom-focused and skill-building methods. Patients with internalizing or inhibited coping styles respond more favorably to interpersonal and insight-oriented procedures. Beutler has also found that patients with low amounts of social support do best in interpersonal and family therapies. In this way, SPP recommends research-supported prescriptive matches to improve the effectiveness and efficiency of psychotherapy. I urge readers to peruse the chapters in the present volume by Stricker and Gold on integrative psychotherapy, and Sparks, Miller, and Duncan on approaches accentuating common factors. Readers are also encouraged to compare and contrast what I have presented and what is emphasized by Zinbarg and Griffith on behavior therapy, and by Kellogg and Young on cognitive therapy. When follow-ups of clients, after responding well to traditional behavior therapy, revealed a fairly high relapse rate, it was obvious that something had to be altered in the treatment protocol to make positive treatment outcomes more durable. It seemed to me that the book I had coauthored with Wolpe on behavior therapy techniques (Wolpe & Lazarus, 1966) downplayed the significance of cognitive processes. More stable outcomes ensued when I added cognitive restructuring to my treatment armamentarium. Moreover, as a technical eclectic, I also drew on emotive imagery, methods from Gestalt therapy, and psychodrama, and I used other techniques that fitted into social cognitive theory that I had learned in various workshops. I termed this approach broad-spectrum behavior therapy and described it in what is arguably one of the first books on cognitive-behavioral therapy (Lazarus, 1971). Although I became more satisfied with my treatment outcomes and follow-ups, I was still aware that certain gaps and lacunae, if identified and remedied, were likely to yield even better results. It seemed logical to seek answers to this conundrum by studiously comparing the differences among former clients with positive follow-ups versus those whose improvements did not last. The foregoing research took place circa 1970 to 1972 when I served as Director of Training in the Department of Psychology at Yale University. This work continued when I joined the faculty at Rutgers University in 1972. Some of the key figures who played a significant role in my developing technical eclecticism and multimodal therapy include Joshua Bierer in London (1957), Albert Bandura, Walter Mischel, Gerald C. Davison, and Michael Conant at Stanford University (1963 to 1964), Perry London at the University of Southern California (1965), Aaron Beck at the University of Pennsylvania (1967 to 1970), and Albert Ellis at his Institute in New York City (1973 to 1983). It needs to be understood that MMT is not a unitary or closed system. It rests on a social and cognitive theory, and uses technical eclectic and empirically supported procedures in an individualistic manner. The overriding question is mainly, “Who and what is best for this client?” Obviously no one therapist can be well versed in the entire gamut of methods and procedures. Some clinicians are excellent with children, whereas others have a talent for working with geriatric populations. Some practitioners have specialized in specific disorders (e.g., eating disorders, sexual dysfunctions, posttraumatic stress disorder, panic, depression, substance abuse, or schizophrenia). Those who employ multimodal therapy will bring their talents to bear on their areas of special proficiency and employ the BASIC ID as per the foregoing discussions and, by so doing, possibly enhance their clinical impact. If a problem or a specific client falls outside their sphere of expertise, they will endeavor to effect a referral to an appropriate resource. Thus, no problems or populations per se are excluded. The main drawbacks and exclusionary criteria are those that pertain to the limitations of individual therapists. Multimodal therapy is predicated on the assumption that most psychological problems are multifaceted, multidetermined, and multilayered, and that therefore comprehensive therapy calls for a careful assessment of seven parameters or “modalities”—Behavior, Affect, Sensation, Imagery, Cognition, Interpersonal relationships and Biological processes. These ideas are taught in several American universities and clinics where my former students are employed, and they, in turn, have schooled others in the multimodal tradition. Through several foreign translations of some of the books and chapters on MMT, therapists in several countries have been adapting and applying MMT in their work. In the broadest terms, our personalities stem from the interplay among our genetic endowment, our physical environment, and our social learning history. The basic social learning triad—classical (respondent) conditioning, operant (instrumental) conditioning, and modeling and vicarious processes—does not account for the fact that people can override the best-laid plans of contiguity, reinforcements, and example by their idiosyncratic perceptions. People do not respond to their real environment but rather to their perceived environment. This includes the personalistic use of language, expectancies, selective attention, goals, and performance standards as well as the impact of values, attitudes, and beliefs. People do not react automatically to external stimuli. Their thoughts and perceptions will determine which stimuli are noticed, how they are noticed, how much they are valued, and how long they are remembered. Thus, the multimodal clinician endeavors to understand each client’s perceptions, expectancies, communications, and metacommunications, and seeks to gain access to his or her phenomenological world by exploring the interplay among each of the seven modalities of the BASIC ID. At the physiological level, the concept of thresholds is most compelling. There are individual differences among people vis-à-vis pain tolerance thresholds, stress tolerance thresholds, and frustration tolerance thresholds, plus wide divergences across a host of other stimuli such as noise, sunlight, heat, cold, and fatigability, to mention a few. Although psychological interventions can undoubtedly modify various thresholds, the genetic diathesis will usually prevail in the final analysis. Thus, a person with an extremely low pain tolerance threshold may, through hypnosis and other psychological and physiological means, learn to withstand pain at somewhat higher intensities, but a penchant for overreacting to pain stimuli will nevertheless endure. The person whose autonomic nervous system is stable will have a different personality from someone with labile autonomic reactions. The latter are apt to be anxiety-prone and tend to become pathologically anxious and depressed under stressful conditions. Since time immemorial, it must have been obvious that some people have a sunny and optimistic disposition, whereas others are morose and cantankerous. People tend to favor some BASIC ID modalities over others. Thus, we may speak of a “sensory reactor,” or an “imagery reactor,” or a “cognitive reactor.” This does not imply that a person will always favor or react in a given modality but that over time, a tendency to value certain response pattern can be noted. Thus, person whose most valued representational system is visual will be inclined to respond to and organize the world in terms of mental images. A person with a high frustration tolerance but a low pain tolerance—someone who is extremely active and whose mental imagery is penetratingly clear—is bound to have a very different personality from someone who succumbs easily to frustration, who is at best moderately active, deeply analytical (cognitive), and incapable of forming more than fleeting visual images. The multimodal approach tends to highlight 10 factors that underlie or interface with emotional disorders and psychopathology. In the broadest terms, psychological difficulties stem largely from genetic and constitutional predispositions, coupled with unfortunate social learning contingencies and problematic environmental events. The aforementioned 10 factors are considered the main factors or instigators in the development of difficulties. A more fine-grained analysis of how emotional difficulties are generated would speak to (a) conditioned associations, (b) rewards and punishments that followed innumerable actions and reactions, (c) the models with whom we identified and whom we imitated—deliberately or inadvertently. These events may have led to conflicting information, faulty cognitions, inhibitions, and needless defenses. It is worth reiterating that emotional problems also arise from inadequate or insufficient learning. Here, the problems do not arise from conflicts, traumatic events, or false ideas. Rather, gaps in people’s repertoires create significant problems if they were never given necessary information and failed to acquire essential coping processes, thus rendering them ill-equipped to deal with many societal demands. In addition to biological malfunctions, the multimodal view emphasizes that most clients suffer from conflicts, the aftermath of unfortunate experiences, and deficits in their social and personal repertoires. Hence unimodal or bimodal remedies are bound to leave significant areas untouched. This stands in contrast to a still prevalent view that psychological difficulties are symptoms of underlying pathological processes, as symbols of unconscious processes. The goals of therapy are essentially twofold—to alleviate suffering and to enhance well-being. Like most cognitive-behavioral therapists, multimodal counselors or clinicians see much of psychotherapy as an educational process that focuses heavily on social skills training and self-management. In the multimodal tradition, the key goals are to remedy any and all significant problems across a client’s BASIC ID. We often draw up a list of specific problems in each modality and the proposed solutions (referred to as a Modality Profile). Assume that a client who sought help because of a generalized anxiety disorder had the following discrete and interconnected problems: The key goals would be to eliminate virtually all the preceding troubles and tribulations, so that the client could emerge from therapy feeling self-confident, pleased with his life, and free from his bothersome shortcomings. To arrive at this point, a wide array of methods would be applied including behavioral activation, relaxation training, coping imagery, social skills training, homework assignments, and cognitive restructuring. In MMT, assessment is certainly not irrelevant. An assessment that culminates in a clear list of problems and proposed solutions across an individual’s BASIC ID is a thorough and elegant evaluation because it provides a template of what needs to be changed or addressed, and how to remedy specific problems. Dissimilar scenes and settings call for different assessments: when dealing with children, when handling crises, when assessing psychotic individuals or other seriously disturbed inpatients, when the client is intellectually challenged, and so forth. Most of my own work has taken place in a private practice setting, and so I will describe my typical assessment strategies with that in mind: With literate clients who are not too depressed or otherwise unable or unwilling to comply the Multimodal Life History Inventory (MLHI; Lazarus & Lazarus, 1991, 2005) saves a great deal of time. Instead of taking up consulting time to obtain a routine history, the clients fill out the 15-page MLHI. It provides the essential antecedent factors, describes ongoing problems, and covers the BASIC ID. This information is valuable, even for therapists who are not MMT practitioners. At the start of an initial session, like most therapists, the MMT clinician will endeavor to establish rapport by creating an atmosphere wherein the client feels safe, heard, understood, and accepted. Presenting problems will be heard and the therapist will usually inquire about antecedent events, ongoing behaviors, and explore the various consequences that have ensued. By the end of the initial session, some helpful suggestions may have been made, a preliminary plan of action will usually have been formulated, and when necessary, the therapist will have obtained informed consent from the client to proceed. At the end of the first meeting, most clients receive a copy of the MLHI and are asked to complete it at home, and bring it with them to the second session. The therapist generally studies the MLHI before the third session, but at some point in the second meeting, it is customary to at least glance through the questionnaire—often to find any items that may have been omitted or glossed over, and this may be discussed if time permits. In MMT, assessment is always ongoing as new facts come to light and various misconceptions are corrected. Formal and standardized assessments may be conducted as needed, and most of these will usually be done within the first three or four sessions. Included herein might be referral to a physician to shed light on a suspected medical problem, to a psychopharmacologist to determine if medication needs to be part of the treatment, or referral to a neuropsychologist for a battery of tests if this seems warranted. The old aphorism about benefiting by learning from the past, living well in the present, and planning for the future are part and parcel of the MMT trajectory. All three of the preceding elements become the foci of attention without spending too much time in the past. As a relevant aside, the imagery modality is most important for trying to ensure the success of future plans. It is usually necessary to be able to picture oneself achieving a goal, before success is likely to ensue. Toward the end of therapy, when it is hoped that most problems will have been resolved, MMT clinicians are apt to apply successful time projections and coping images so that the client feels confident about transcending his or her gains. Multimodal therapists pay close attention to the individual and his or her idiosyncrasies, as well as the person in his or her social setting. Indeed, the pendulum swings back and forth between these issues depending on the problems being addressed. A schematic design of the BASIC ID would depict a triangle with the biological modality as its base (because our neurophysiological and biochemical processes underlie all else), and the interpersonal modality would be the apex of the triangle (because other people are so fundamental to our well-being). The macrosystem is also always considered (issues pertaining to diversity and culture, work or school pressures, specific peer relationships), and an understanding of the client’s primary dyadic transactions and family issues is essential. In most instances when traversing the interpersonal modality, spouses, family members and other people who play a significant role are brought into the therapy. In general, because of the didactic and pedagogical thrust of the multimodal approach, the therapist tends to be active—often modeling, role playing, rehearsing, instructing, coaching, relaxing, and accompanying the client outside the office as in exposure therapy or in vivo desensitization. But there are times when the therapist is little more than an attentive listener or a sounding board. The therapist pays heed to the impact of each intervention and modifies what he or she says or does accordingly. When it is evident that the client needs to unburden him- or herself or to focus on historical material, unless there are reasons to discourage this (as when some people are inclined to dwell in and on the past to their own detriment), the client’s needs are honored. The therapist listens and tries to empathize with and understand the client. Therapists who insist on behavioral activation and bypass the subjective thoughts and feelings that the client may wish to pursue are likely to create a rupture in the relationship. Selective, relevant, and appropriate self-disclosure is often extremely beneficial to the process and outcome of psychotherapy. These disclaimers imply that if a therapist is self-disclosing entirely for his or her own benefit, one may wonder about its appropriateness. The orthodox psychoanalytic emphasis on the analyst’s avoidance of any self-revelation so as to maintain the “blank screen” on which the patient can project his or her perceptions has spilled over into the field in general. Two faulty guidelines still appear in various camps: “Don’t answer any of the patients’ questions, and don’t say anything about yourself.” This advice is most unfortunate because observation and the sharing of experiences are fundamental ways that learning takes place. The therapist who discloses little or nothing about him- or herself may be depriving the client of a vital learning experience essential for change. “I used to be anxious about public speaking,” confides a therapist, “until I used special relaxation and imagery techniques. Let me teach them to you and see if you derive as much benefit as I did.” This type of self-disclosure has led many clients to comment that they developed a greater sense of trust and fondness for the therapist. They were pleased to know that their counselor was not someone who worked solely from book knowledge, but had a personal understanding of what they were experiencing. There are exceptions to almost every rule. Thus, with some clients, a counselor or therapist who admits to being less than perfect may be seen as defective. “What do you mean you sometimes feel a little down in the dumps? Physician heal thyself!” Nevertheless, responses of this kind can be used as grist for the mill. I have also met therapists who brag and talk incessantly about themselves to their clients, and that my strong endorsement of self-disclosure as valuable should not be seen as a license to seek therapy for oneself at the patient’s expense. Depending on the nature of the problems, my therapy lasts anywhere from 1 to 50 sessions, or more. About 50% of my clients are seen weekly for 12 to 20 sixty-minute sessions. About a third may see me for about 20 sessions over the span of a year or two. In most of these cases, fairly long intervals elapse between sessions while they perform homework assignments. At the opposite extreme are people in acute crises who are seen daily for a couple of weeks. But the most typical length of therapy is between 10 and 15 sessions. The therapeutic alliance is the soil that enables the methods and techniques to take root. In some instances, the alliance is necessary and sufficient. Some people see psychotherapy as the purchase of friendship. In most cases, a good alliance is necessary but insufficient. The field of therapy has evolved to the point where there are now treatments of choice for specific conditions. Twenty-first-century psychotherapy undoubtedly will focus on innovative dismantling studies as they have come to be called. The endeavor here is to parcel out the precise factors that promote therapeutic efficacy. In both clinical and experimental settings, clinicians may determine what role the patient-therapist relationship played, and the extent to which therapeutic expectancies and other nonspecific ingredients were an integral part of treatment outcomes (see Barlow, 2002). Randomized controlled trials (RCTs) can identify overlapping and sequential elements in therapy. They point to what is necessary and sufficient to promote successful treatment outcomes. Twenty-first-century researchers and clinicians will extend the emphasis on accountability: the need to establish various treatments of choice and to understand their presumed mechanisms. One may predict that twenty-first-century psychotherapy will underscore treatment efficacy and generalizability across different methodologies. Benchmarking, first described by McFall (1996), will also be amplified. This refers to studying treatments of established efficacy through RCTs and applying them in clinical service settings with unselected clients. The outcome in the service setting is then compared with RCTs in research laboratories (see Wade, Treat, & Stuart, 1998). Basically, it would appear that manual-based procedures produce outcomes in clinical service settings that are comparable to those obtained in RCTs. What is perhaps most needed is a fuller understanding of the necessary and sufficient forms and levels of therapist training and expertise. There is a crucial question: What technical expertise and interpersonal skills do therapists need to work in a clinically sophisticated manner? Under “interpersonal skills” I include the artistry that I believe will always play a significant role in such matters as judgment, demeanor, and timing. In multimodal therapy, many of the techniques employed fall under the rubric of cognitive-behavioral therapy (CBT) because most of their techniques have empirical backing. Some strategies, however, are unique to MMT. This strategy can readily be taught to novices through the BASIC ID format. 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 his 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 his feelings only yield similar abstractions. It is often counterproductive to confront the client and point out that he is evading the question and seems reluctant to face his true feelings. In situations of this kind, bridging is usually effective. First, the therapist deliberately tunes into the client’s preferred modality—in this 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- to 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 to focus on them, often with a hypnotic overlay. “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, 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 am in touch with anger and with 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. 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 ID assessments. 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-I-S-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 him or her in an altered state of consciousness—deeply relaxed with eyes closed—contemplating untoward events and then describing their reactions. One of my clients was perplexed that she frequently felt extremely anxious “out of the blue.” Here is part of an actual clinical dialogue: Therapist: Now please think back to those feelings of anxiety that took you by surprise. Take your time, and tell me what you remember. Client: We had just finished having dinner and I was clearing the table. (Pause) I remember now. I had some indigestion. Therapist: Can you describe the sensations? Client: Sort of like heartburn and a kind of a cramp over here (points to upper abdomen). Therapist: Can you focus on the memory of those sensations? Client: Yes. I remember them well. Therapist: (After about 30 seconds) What else comes to mind? Client: I started to breathe more quickly, and then I said, “Here I go again.” Therapist: Meaning? Client: Meaning, I’m probably going to end up having another migraine. Therapist: How did you come to that conclusion? Client: Well, I started imagining things. Therapist: Such as? Client: Such as the time I had dinner at Tom’s and had such a migraine that I threw up. Therapist: Let me see if I am following you. You started having some digestive discomfort, and then you noticed that you were breathing rapidly. . . Client: And my heart started pounding. Therapist: And then you had an image, a picture of the time you were at Tom’s and got sick. Client: Yeah. That’s when I stopped what I was doing and went to lie down. This brief excerpt reveals a sensation-imagery-behavioral sequence. In the actual case, a most significant treatment goal was to show the client that she attached extremely negative attributions to negative sensations, which then served as a trigger for anxiety-generating images. Consequently, she was asked to draw up a list of unpleasant sensations, to dwell on them one by one, and to prevent the eruption of catastrophic images with a mantra—“this too shall pass.” Only general overviews are possible in a single chapter; for more information about bridging and tracking and the multimodal approach, see Lazarus (1989, 1997), and my chapters in O’Donohue, Fisher, and Hayes (2003), Corsini and Wedding (2008), and Norcross and Goldfried (2005). The initial Modality Profile lists clients’ problems across the BASIC ID and translates vague, general, or diffuse problems (e.g., depression, unhappiness, 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 ID 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. Again, I refer the interested reader to Corsini and Wedding (2008), Norcross and Goldfried (2005), and to Lazarus (1997) for more details. When no stumbling blocks or impasses arise, the intervention sequences follow a logical format. The main problems across the Modality Profile (the BASIC ID Chart) will be discussed with the client and prioritized through mutual agreement. Let’s say that the salient problem list for an anxious female patient is as follows: B Tends to avoid too many necessary tasks. Often comes in late for work. Wastes time by lingering too long in supermarkets. Watches late-night TV, which results in insufficient sleep. A Often feels anxious. Also is inclined to feel depressed. Feels inferior. S Headaches, as well as neck and lower back pains. Intermittent gastrointestinal discomfort. Tension in jaws. Frequent palpitations. I Images of failure and ridicule. Nightmares involving censure and condemnation. Flashbacks to scary memories from childhood. I Rather timid and inhibited. Has no close friend. Would like to marry and have a family. Regresses to a childlike state around her parents. D Uses Xanax prn. Neglects to exercise, has poor nutritional habits. Uses over-the-counter painkillers for her various aches and sensory discomforts. Assuming that the client has already seen a physician and received a clean bill of health, the priorities are likely to be: If the aforementioned issues are resolved, it is likely that a ripple effect will generalize to other negative items. If not, the therapy would then focus more on her toxic ideas, proceed to manage her interpersonal withdrawal via assertiveness training, and recommend various support groups where she is likely to make friendships. It may also prove to be necessary to explore the details of her family of origin and determine the viability of some family therapy sessions. Once a Modality Profile (a list of specific problems across a client’s BASIC ID) has been drawn up, the next step is to identify what seems to require immediate attention, and then to prioritize the issues to address thereafter. Usually this is done in concert with the client. The therapist will tend to lead off: “It seems to me that the first thing we need to do is get your anxiety under control. Then we can look into ways of dealing with your concerns over your sister’s intrusiveness, your need to develop a better nutritional program, and your tendency to agree to tasks at work that could be delegated to others.” The clinical decision-making process is flexible. If matters come to light that call for a change, a different ordering or sequence of techniques will be designed and implemented as soon as possible. In general, interventions should have a ripple effect. Thus, a course of deep muscle relaxation together with rhythmic breathing and coping imagery may diminish anxiety, attenuate muscular pain, and lead to a calmer frame of mind. Whenever feasible, behavioral activation is implemented because it is well known that a change in behavior tends to evoke positive shifts in affect and cognition. Clients are often informed that MMT is a psychoeducational process that calls for practice if one is to be successful. “If you want to be a good piano player, or if you want to learn a foreign language, your success will usually be in direct proportion to how hard you practice in between lessons. And so it is with various homework assignments you may be given. Change occurs out there, in your natural habitat. The more different things you do, and the more things you do differently, the better you will feel.” There are practitioners who view presenting problems as “calling cards”—minor issues that the client brings up while deciding whether the therapist is sufficiently trustworthy to be given more personal and relevant disclosures that really brought the client to therapy. These therapists are apt to ignore, bypass, gloss over, or dismiss presenting complaints and look for more basic concerns. Some people may indeed test the therapist with somewhat inconsequential problems before moving to more upsetting and perhaps delicate issues. Nevertheless, if the therapist does not focus on the presenting problems, the client may see the therapist as a poor listener and feel unheard and misunderstood. Besides, there are many instances in which the presenting complaints are undeniably the main problems that have led the client to seek help. Thus, I suggest to my students: “Start by addressing the presenting problems and see where this goes.” Many practitioners are opposed to using medication for psychiatric complaints. It is true that there may be a proclivity in some quarters to overprescribe and to treat with drugs conditions that might be better handled psychologically. Thus, it has been argued that too many depressed people are handed a prescription instead of being taught how not to depress themselves. It is important for people to become aware of how they depress themselves and learn to exercise control over their thoughts, feelings, and behaviors. And perhaps too many anxious people reach for an anxiolytic drug instead of applying antianxiety techniques. But practitioners will surely encounter clients who become unraveled unless they are adequately medicated. Those who argue that mental and behavioral problems are all based on learning are overlooking that brain injury, tumors, arteriosclerosis, mini-infarct dementia, HIV dementia, and so on all create mental and behavioral problems. And there are clear data that hormonal changes are associated with postpartum depression. Biochemical changes associated with pregnancy, premenstrual tension, and sudden cessation of chronic steroid use, to name a few events, can all produce depression, or other abnormal behaviors. In MMT, the D modality goes beyond drugs and includes the panoply of biological and neurophysiological factors that play a significant role. When medical problems are suspected, clients are asked to consult appropriate physicians, and the counselor or therapist, with the client’s permission, often works in tandem with the doctor(s). Beyond medication, the D modality focuses on matters such as rest, relaxation, exercise, nutrition, and the avoidance of harmful substances (smoke, recreational drugs, and too much alcohol). To reiterate, the relationship between client and therapist is the soil that enables the techniques to take root. On occasion, little more than a good therapeutic relationship—a close working alliance—is required. In other instances, the relationship serves as a springboard to ensure that the client will comply with the homework assignments, and use the methods and techniques that are being implemented. An agoraphobic client who needs to proceed farther and farther from a safe haven may commence by taking longer walks while accompanied by the therapist. If the therapist is not regarded as a trusted protector—if adequate rapport and a good liaison do not exist—little progress is likely to ensue. This is an obvious example of when the relationship plus a specific technique go hand in hand. Insight and cognitive restructuring have an important role to play in some cases, but unless they are accompanied by some overt behavioral changes (for the better), the actual gains may be less than meaningful. A client may state that he or she has gained insight into the fact that a hypercritical mother had laid the groundwork for demanding and disparaging judgments that the client had imitated and mirrored. This insight would have no real value unless the client (and his or her associates) can show that it resulted in far less hostile and nitpicking behavior. It was the psychoanalyst Allen Wheelis (1963) who wrote that one can attain “insight to spare but no change.” Hence my tendency to ask my clients, “What have you done differently, and what different things have you done?” Using a football analogy, I have stated that it is not necessarily the quarterback who tries to take the ball into the end zone. If he sees a man downfield in a good position, he throws the ball to him, hoping to gain yardage or score a touchdown. And so it is with the MMT clinician who will seek help from, or refer the client to, other counselors who might be in a better position to help the client. If necessary, one goes outside the field of psychotherapy to draw on resources that might enable clients to reach their aims and goals (see my case study in Stricker and Gold’s 2006 book). Cultural and multicultural issues are obviously at the forefront. One of the first questions a therapist should ask is, “Am I the most suitable person for this client?” Many factors can lead one to feel that some other counselor or therapist would be more suitable. The client may present problems or issues in which the therapist is not well schooled. It may soon become apparent that the client would derive benefit from a different therapist, using different methods. And cultural, linguistic, and gender differences are inclined to be prominent in this respect. In many instances, it may be advisable to refer the client to a counselor who is fluent in a different language, or who is of a different race or gender. Several African American students have informed me that they had used the BASIC ID format to excellent effect with their confreres and that the populations they served were most unlikely to have responded positively had I been their therapist. There are skillful multimodal therapists who work extremely well with children or adolescents. Others have an aptitude for dealing with geriatric clients. Some of my former students have a gift for dealing with various Axis II disorders. There are those who have specialized in treating specific disorders (e.g., eating disorders, sexual dysfunctions, PTSD, panic, depression, substance abuse, or schizophrenia). Those who employ multimodal therapy will bring their talents to bear on their areas of special proficiency and employ the BASIC ID as in the foregoing discussions, and possibly enhance their clinical impact. The point here is that MMT providers possess and use a comprehensive template that holds them in good stead regardless of the situation or setting. Most clients are likely to show positive gains when receiving a broad-spectrum treatment that addresses salient issues. The implementation of the assessment and therapy procedures requires the clients’ compliance, and for this, the match between the participants (more so than the specific problem area) is a main concern. This point was mentioned earlier. One cannot point to specific diagnostic categories for which the MMT orientation is especially suited. MMT offers practitioners a broad-based template, several unique assessment procedures, and a technically eclectic armamentarium that permits the selection of effective interventions from any sources whatsoever. Yet given the emphasis placed on established treatments of choice for specific disorders, and the weight attached to using empirically supported methods, MMT typically draws on methods employed by most cognitive-behavioral therapists. The cognitive-behavioral literature has documented various treatments of choice for a wide range of afflictions including maladaptive habits, fears and phobias, stress-related difficulties, sexual dysfunctions, depression, eating disorders, obsessive-compulsive disorders, and posttraumatic stress disorders. We can also include psychoactive substance abuse, somatization disorder, borderline personality disorders, psychophysiological disorders, and pain management. There are relatively few empirically supported treatments outside the area of cognitive-behavioral therapy (CBT). Thus, CBT, more than any other approach, has provided research findings matching particular methods to explicit problems. Most clinicians of any persuasion are likely to report that Axis I clinical disorders are more responsive than Axis II personality disturbances. Like any other approach, MMT can point to many individual successes with patients diagnosed as schizophrenic, or with those who suffered from mood disorders, anxiety disorders, sexual disorders, eating disorders, sleep disorders, sexual disorders, and the various adjustment disorders. But there are no syndromes or symptoms that stand out as being most strongly indicated for a multimodal approach. Instead, MMT practitioners will try to mitigate any clinical problems that they encounter, drawing on the scientific and clinical literature that shows the best way to manage matters. But they will also traverse the BASIC ID spectrum in an attempt to leave no stone unturned.
TECHNICAL ECLECTICISM AND MULTIMODAL THERAPY
HISTORY OF THE APPROACH AND ITS VARIATIONS
Beginnings
Populations/Places Where Developed
Key Figures and Variations of Approach
THEORY OF PERSONALITY AND PSYCHOPATHOLOGY
View of Health and Pathology
View of the Development of Difficulties
THEORY OF PSYCHOTHERAPY
The Goals of Psychotherapy
ASSESSMENT
Is There a Special Assessment Phase?
Foci of Assessment
The Process of Psychotherapy
Level of Activity
Self-Disclosure
Typical Length of Therapy
Role of the Therapeutic Alliance
STRATEGIES AND INTERVENTIONS
Bridging
Tracking the Firing Order
SECOND-ORDER BASIC ID ASSESSMENTS
Typical Sequences in Intervention
Typical Clinical Decision Process
HOMEWORK
How Strategies Are Adapted to Specific Presenting Problems
View of Medication
Curative Factors
Special Issues
Culture and Gender
ADAPTATION TO SPECIFIC PROBLEM AREAS
Empirical Support
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