Essay title - The Major Tenets And Essential Techniques Of Adlerian And Multimodal Therapies
Abstract
The following paper highlights the major tenets and essential techniques of Adlerian and Multimodal therapies. A brief analysis of the problem and a treatment plan, including the use of common factors in facilitation of positive outcomes, to address the difficulties experienced by “Janet” (a fictional client) from each of these perspectives is also provided.
My personal learning regarding the nature of theory as well as the relationship of common factors to the application of theory are also included in this paper.
Adlerian Therapy
Major Tenets
Adlerian Individual Psychology (AIP) is a humanistic, holistic approach to therapy and emphasizes the uniqueness and unity of an individual, versus viewing humans as a multitude of independent constituents. AIP stresses social psychology (humans have an innate drive to be productive in society), a positive view of human nature (humans are not merely influenced by biological drives and are both influenced by and have influence on their environment and experiences). One’s subjective interpretation of early experiences leads to the creation of a lifestyle or “plan of life” (Corey, 2005, p.97) within the first six years of life. Idealistic beliefs about the world are also formed and influence behavior (fictional finalisms) within one’s life plan.This lifestyle remains consistent and shapes their personality (beliefs about themselves, others and the surrounding world) and methods of dealing with life’s tasks.
Consciousness is seen as the center of personality: thoughts lead to feelings which lead to actions. All actions are purposeful, as humans are viewed as teleological (goal-oriented). Based on a growth model (helping one reach their full potential), AIP stresses that a person possesses a positive capability to live fully in society via these purposeful goals. Personality as viewed as unified and thus it is essential to understand an individual’s world form a phenomenological (subjective reality) viewpoint. AIP stresses that humans create purposeful life goals that give direction to behavior. Humans are motivated by a sense of belonging and having a salient role in society – a concept known as social interest. Social interest encompasses “the intellectual, affective, and behavioral aspects of the optimal relationship to others, namely, understanding, empathizing with, and acting on behalf of others” (O’Connell, 1965, p. 47) and is at the heart of one’s lifestyle, as it is seen as innate.
Feelings of inferiority, first experienced during infancy, create a drive for perfection or superiority, in attempt to compensate for inferiority, which further fosters one’s social interest. Social interest is individually defined by one’s unique lifestyle which is created during the first six years of life. Through socialization (during childhood), social interest is also fostered and “involves finding a place in society, acquiring a sense of belonging and contributing … and striving for a better future for humanity” (Corey, 2001b). Striving for superiority and social interest through mastery and perfection is the main motivational factor for all human behavior.
The Process
It is believed that “[t]he degree to which [humans] successfully share with others and are concerned with the welfare of others is a measure of [one’s] mental health [or discouragement]” (Sherman & Dinkmeyer, 1987). Therefore, AIP aims to challenge client’s mistaken notions or basic mistakes (faulty, self-defeating perceptions and beliefs that shape personality and include denying self-worth, an exaggerated need for security, and setting unattainable goals; Corey, 2001a). Therapists create a mutually respectful, equal and active therapeutic relationship, focusing on the client’s strengths (to instill hope and optimism for change) in order to gain in-depth insight into the client’s subjective experience and view of their world. Therapists then encourage clients to develop socially useful goals and live on the useful (versus socially isolated and therefore useless) side of life through a four-phase framework, each with a corresponding objective: Establishing the proper therapeutic relationship; assessment (exploring the psychological dynamics operating in the client); insight and purpose (encouraging the development of self-understanding); and reorientation and reeducation (helping the client make new choices (Dreikurs, 1997).
By examining the client’s plan of life, including recollections of early experiences that serve to support their present life philosophy (Corey, 2001a), expressed through every facet of the client’s way of being (thoughts; feelings; behaviors), therapists interpret and convey the connection between a client’s past, present and future striving. Therapists help clients view themselves, others and life in general from new perspectives via a “cognitive map [, which serves to foster] a fundamental understanding of the purpose of their behaviors” (Corey, 2005, p. 101). Functioning as technically and theoretically eclectic, therapists use a plethora of techniques, chosen based on their clinical experience and knowledge of what is most appropriate for the client’s individual needs, from within any theoretical framework, to support this process of client growth.
Criticisms
The construct is difficult to validate empirically (i.e., not easily replicated) because the concept of being driven by social interest is vague and imprecisely defined and because theoretical eclecticism leads to confusion for both therapist and client, as it attempts to amalagamate incompatible theoretical constructs and (Lazarus, 1995).
The AIP approach also offers an oversimplified explanation of the complexity of human functioning (i.e., motivated by one drive; all behaviors reduced to one goal) and thus relies too heavily on a commonsense perspective. To the contrary, its in-depth exploration of childhood memories and experiences may be seen as intrusive to clients from some cultures (i.e., collectivist societies). However, if the AIP therapist is aware of and sensitive to the client’s culturally held value of familial privacy, the client may be more willing to engage in assessment and treatment procedures (Carlson & Carlson, 2000).
AIP therapists are not “problem-solvers”, as they view their role as teaching clients coping methods. Clients who hold the cultural value that therapists are “experts” may find AIP frustrating and thus limited in its utility.
Generalizability
AIP has been integrated in several major therapies (i.e., cognitive behavioral therapy; family therapy) because of its ground work in a humanistic versus deterministic view of human nature and also has wide applicability to counselling diverse populations, as it emphasizes an interpersonal and phenomenolocial frame of reference (Corey, 2001a, 2005).
AIP is easily adaptable to brief therapy formats. Adler was in favor of a time-limited therapeutic intervention and thus his techniques (and those created by other Adlerian therapists) are used in many contemporary brief therapies (Watts, 1999).
Techniques
AIP therapists are technically eclectic – they employ techniques from a multitude of cognitive, behavioral and experiential techniques, as well as creating their own strategies for supporting client change. The treatment plan is comprised of techniques that are specific to each unique client. However, there are techniques inherent to AIP, including acting “as if” (life is the way the client wants it to be/is capable of making it), the magic wand technique (to describe the ideal life/goal), interpretation of a family constellation questionnaire (initial source of view of self, other and the world), early recollections (used as a diagnostic tool to identify convictions, evaluations, attitudes, and biases interviews (subjective and objective), personality priorities (initial behavioral response pattern to perceived stress), encouragement, summarizing, confrontation (of basic mistakes), paradoxical intention (“the deliberate practice of a neurotic habit or thought, undertaken in order to identify and remove it”)(retrieved March 3, 2008 from http://en.wikipedia.org/wiki/Paradoxical_intention), and homework assignements (Griffith & Powers, as cited in Corey, 2005; Corey, 2001a; Corey, 2001b; Dreikurs, 1997; Kefir, 1981). .
AIP has high prescipritve efficacy. The techniques are aimed at helping clients create new patterns of behavior, develop encouraging perspecitives, and access strengths and resources (through identifying and combating discouraging cognitions; generate perceptual alternatives, focus on efforts not merely outcomes; and emphasize assests, resources and strengths (assessing and fostering insight into the client’s functionality or degree of social interest, determined by their phenomenological view of themselves, others and the world. The origins of and congitive processes that contribute to their level of social interest are identified and challenged and the client is empowered to establish a life plan or goal that will increase social connectedness and sense of community and contribute to humanity.
The “Problem”
The heart of Janet’s problem lies in her diminshed sense of social interest. Because of her lack of sense of community due to her social withdrawl (from church groups and United Way) and familial detachment (i.e., divorce; children out of the home), she has ceased to actively realize or make true the fictional finalism (developed as part of her lifestlye plan during the first six years of her life with high achieving and socially engaged parents) she holds of her life as a high social achiever. She is not living on the useful side of life.
Treatment plan
I would encourage Janet to develop socially useful goals and live on the useful (versus socially isolated and therefore useless) side of life through a four-phase framework, each with a corresponding objective, based on Dreikurs’s (1997) framework.
Phase 1: Establishing the proper therapeutic relationship
I would create a therapeutic communicate professional, mutual respect, and a partnership in unearthing the client’s teleological perspective by being humble and human and taking into account Janet as a whole person (versus dissecting her personality constituents). I would focus on her strengths (i.e., competency; ability to succeed via past successes) to instill hope and create an environment conducive to positive change (moving towards the useful side of life).
Phase 2: Assessment (exploring the psychological dynamics operating in the client)
I would conduct a subjective interview, encouraging Janet to tell her life story completely, including her stoic family of origin, divorce and current life, by using empathic listening, attending and demonstrating genuine intense sense of interest.
From this, I can identify “patterns in Janet’s life, develop a hypothesis about what works for her, and determine what accounts for her various concerns” (Bitter et al, as cited in Corey, 2005). I’d end the interview with the question, “How would your life be different, Janet, and what would you do differently, if you did not have difficulty sleeping, lethargy and feelings of loneliness and bitterness?”. This will enable me to detect organic problems and identify symptoms that help Janet avoid a task she deems necessary (i.e. re-joining the church group to feel socially connected and competent).
I’d then conduct an objective interview to uncover information about how problems in Janet’s life began (i.e., precipitating events; medical history), social history, reasons Janet choose therapy at this time, current coping strategies, and lifestyle assessment (Corey, 2005). The lifestyle assessment would include information about Janet’s family constellation and early childhood experiences, which sheds light on Janet’s plan of life and fictional finalisms, interpretations, coping styles and personality priorities.
I would then present Janet with a narrative summary of her personal life story, including strengths, interfering ideas and coping strategies. I’d include an analysis of Janet’s basic mistakes to identify how Janet’s mythical thinking is causing her to act as if the myths were true (i.e., “I must always be active and achieving in order to be worthy”).
Phase 3: Insight and purpose (encouraging the development of self-understanding)
Using paradoxical intention, I’d encouraged Janet to intensify each of her symptoms (feelings of loneliness and bitterness; lethargy) in order to increase his/her awareness of the symptom and its consequences. This will aid Janet in seeing the absurdity of her symptoms.
I’d also use well-timed interpretations to foster insight. I’d use statements such as, “I wonder if the reason you are having trouble sleeping is because you feel a diminished sense of social connectedness?”
Phase 4: Reorientation and reeducation (helping the client make new choices)
I would help Janet discover more functional ways of coping with life and increasing her sense of social interest by prescribing homework assignments. I’d help Janet find the courage to re-join her church group and re-engage in her supportive efforts with the United Way.
Multimodal therapy
Major Tenets
TRACI treating stress and emotion as if they were separate fields is absurd, and who notes “…where there is stress, there are also emotions…” (Lazarus, as cited in Clarke, 2000).
Grounded in social learning (e.g., Bandura, 1977; Rotter, 1954) and cognitive theories, Multimodal Therapy (MMT) is a systematic, holistic and comprehensive approach to behavior therapy (Corey, 2005) founded on the belief that humans are social beings who move, feel, sense, imagine, interact and think (Corey, 2005; Lazarus, 2006). Guided by this social-cognitive model, MMT rests on testable developmental factors such as modeling, observable learning, the acquisition of expectancies, operant and respondent conditioning, and various self-regulatory mechanisms (Lazarus as cited in Perkins, n.d.). It aims to brief but comprehensive and effective in achieving durable results (Corey, 2005) by setting clear, concise, action-oriented goals and focusing on identifying and targeting maladaptive behaviors (asks what when and how and is less concerned with why) across all dimensions of personality that are occurring within the client’s current environment and life circumstances. The goal of therapy is to apply a breadth of the most effective techniques to in addressing all specific client issues in order to increase adaptive coping and functional skills. Once clients master effective coping skills and processing skills for specific problems, they can apply these skills to other problems as they arise.
MMT is guided by the assumption that humans are both the product and producer of their environments and are troubled by a multitude of specific problems within seven discrete but interactive and reciprocally influential modalities or dimensions of personality/psychology. These modalities are: Behavior (overt actions that are observable and measurable), affective responses (emotions; moods; feelings), sensory reactions (seeing; hearing; touching, smelling; tasting), images (mental pictures), cognitions (i.e., thoughts; ideas; values), interpersonal relationships, and the need for drugs and other biological interventions (exercise; nutrition; substance use). These modalities form one’s BASIC ID (a mnemonic acronym taken from the initial letters of the foregoing modalities that is easy for clients to remember) and are linked by complex chains of behavior and other psychophysioloigical processes (i.e., cognitions) (Lazarus, 2006).
The BASIC ID serves as the main framework of MMT. MMT contends that many problems arise from misinformation and missing information and response patterns that become conditioned in a maladaptive order. Thus clients come to therapy to learn (via observation and psychoeducation) and master coping and functional (i.e., cognitive restructuring) skills. MMT aims to tailor therapy to the full range of the client’s difficulties within each modality. Maladaptive functioning (thoughts, feelings and behaviors) within each modality are identified and treated via teaching, coaching, training, modeling, and directing clients towards helping them meet their goals. The client can then generalize these skills to other existing and future life problems.
The client completes an in-depth lifestyle questionnaire (Multimodal Life History Inventory; Lazarus & Lazarus, 1991) that includes general information, personal and social history, and description of presenting problems. This inventory helps identify the complex cognitive links between the modalities by assessing antecedents, current problems and maintaining factors of the problems. The therapist, in collaboration with client, uses the BASIC ID and inventory to create a modality profile (Lazarus, 1973). The profile identifies specific difficulties in functioning in each of the 7 modalities, the cognitions that link each modality, and specific treatment techniques for each specific issue.
Multimodal therapists are systematically technically eclectic whereby the therapist relies on previous clinical experience and empirically tested treatments to choose a breadth of specific interventions that are appropriate and for each specific issue within each modality (Norcross, 2005). However, therapists remain theoretically consistent, drawing mainly from broad-based social and cognitive learning theories because their tentes are open to verification or disproof and empirically tested. Although the techniques employed originate from various psychotherapeutic models, they can be explained by social and cognitive learning principles (Lazarus, 1989). Therapists also conduct ongoing careful evaluation of whether or not each technique is working to effect change and adjust the treatment to achieve the client’s goal, as it aims to brief in duration (approximately 5-10 sessions) and highly effective (i.e., prevent relapses).
MMT has moderate descriptive utility because the two main constituents of the theoretical concept (social learning and cognitive theory) themselves are easy to understand and explain a large range of maladaptive (human) behaviors. However, this may pose difficulty in understanding which specific principle of which theory is used to form and describe one concise construct. This, as well as relying somewhat on clinical experience in choosing techniques, leads to potential difficulty in training a therapist to know which principle is guiding which chosen technique and to know exactly which technique to use for each specific client difficulty.
Criticisms
This “Do what you think will work” approach to therapy has received much criticism as it is believed by some to “pollute the theoretical purity of behavior therapy and divert the attention of … clinicians from their commitment to scientific formulations and evaluation” (Davison & Neale, 1978, p. 517). Other criticisms include the instability and unreliability of technical eclecticism as it does not work from within one theoretical framework (Davison & Neale, 1978) and thus fails to describe how techniques drawn from divergent theories fit together. However, MMT is technically eclectic versus theoretically eclectic (amalgamating the principles of more than one theory of counselling). According to Lazarus (1995), theoretical eclecticism leads to confusion because underlying assumptions of various theories may be incompatible, whereas multimodal therapy is theoretically consistent in that all techniques employed by multimodal therapists can explain in line with social learning and cognitive theory principles. Brief MMT is “efficient, effective, teachable, [and] demonstrably valid …” (Lazarus, as cited in Corey, 2005, p. 253). Empirical evidence shows that clients are likely to show and maintain positive gains when receiving a broad-spectrum treatment in which salient issues are addressed (Kwee, 1984; Kwee & Kwee-Taams, 1994; Williams; 1988).
Generalizability
Because personality is believed to be developed via social learning and mediated by cognitive processes, most maladaptive behaviors across gender and age can be explained by clients having learnt to behave or respond to their environment/events based on the functionality of those responses. MMT is generalizable in a broad sense, to cultures, because the framework (BASIC ID) is based on specific on analysis of the client’s behavior within their sociocultural (i.e., the client’s culturally and socially based conception of the problem) and personal environment (i.e., life context; interpersonal relationships; intrapersonal processes) and empowers client to make changes within that context. Clients follow a concrete behavior change plan that is directly applicable to help them with their specific problems in their unique situation/life.
MMT may be limited by the expectation and assumption that humans naturally trust and engage in therapy quickly. This may prove ineffective or counterproductive with some clients (i.e., shy; non-Western ethnicity; gender or generational belief in non self-disclosure). While the multimodal framework considers many facets in the client’s environment, it does not include a discussion with the client regarding the potential impact of desired changes on these factors. Responses to client change from/within these factors may interact (inhibit or facilitate) with the client’s motivation to and thus impact the likelihood of meeting goals.
Techniques
MMT is considered one of the four routes of Integrative Psychotherapy: Technical eclecticism. It utilizes techniques from a multitude of psychotherapies that are aimed at producing behavior change from other therapies that can be explained by social-cognitive theories, aiming to address the specific areas of client dysfunction within each modality by answering the question “What treatment, by whom, is most effective for this individual with that specific problem and under which set of circumstances (Paul as cited in Corey, 2005)?”. Technical eclecticism is designed “to improve [the] ability to select the best treatment for the person and the problem … guided primarily by data on what has worked best for others [with similar problems] (Norcross, 2005, p.8)”. Commonly used techniques include modeling (e.g., behavioral rehearsal: client observes therapist’s performance in a hypothetical situation and imitates and practices it; video tapes are often used to help facilitate this process)(Lazarus as cited in Davison & Neale, 1978), exposure, empty chair (client more fully explores feelings regarding a real person by directing discussion to an empty chair that is imagined to have that person sitting in it), non-reinforcement (i.e., therapist ignoring client crying and focus on the cognitions or sensations versus the crying behavior), anger/anxiety-management, biofeedback (i.e., biodots), relaxation training (e.g., yoga tapes) , sensate focus training, imagery, bibliotherapy, cognitive restructuring (e.g., therapist challenging faulty thinking and irrational beliefs by teaching clients to ask themselves why they must do/say/feel/think/believe what they do), assertion training, lifestyle changes (e.g., diet; exercise), and medication (pharmacological interventions). (See Lazarus, 1987, for an extensive list of techniques). Techniques are often drawn from the four major behavioral approach branches (classical, operant, social learning and cognitive) (Corey, 2005, p. 251) but Lazarus (as cited in Davison & Neale, 1978), the founder of MMT, argues that therapists must use the technique that is most likely to work for the specific client problem, regardless of its theoretical origin. Therapists also refer clients to experts in order to implement a specific treatment.
Two techniques, however, are specific multimodal procedures – bridging and tracking (Lazarus, 2006).
Bridging
The therapist begins where the client is (i.e., which modality s/he is currently in touch with/operating from) and then bridges into the modality in need of attention (where the targeted maladaptive behavior/thought/affect exists). This way, clients are more willing to traverse the more (emotionally) difficult areas in need of treatment. For example, a client is in need of anger management whereby the underlying fuel for aggressive outburst is feelings of hurt, but the client diverts emotional-based questions by the therapist, and instead discusses cognitions associated with the aggression. It is counterproductive to confront the client and identify the avoidance in discussing emotions. Instead, the therapist tunes into the client’s preferred modality (the cognitive domain, in this case) and explores the cognitive content via dialogue. Merging into a sensate focus on the aggressive behaviors is less threatening then moving directly into affective discourse and the therapists can do so by asking the client to identify any body sensations associated with the aggression. The therapist can then engage the client in a relaxation exercise (i.e., closing eyes; breathing deeply), focusing on the body sensations identified, and then bridge into affect by asking the client to identify any strong emotions associated with the sensations. Clients are, at this point, usually willing to voice their feelings.
Tracking the Firing Order
Clients engage in a fairly reliable pattern of generating negative affect in response to an event/memory/interaction. For example, following a car accident, a client may first dwell on aversive sensations (i.e., neck tension; shaking; hyperventilating), followed by unpleasant images (i.e., pictures of bodily harm), to which they attribute negative cognitions (i.e., ideas about serious injury or death), leading to dysfunctional behavior (avoidance; withdrawal).
It is important to track the client’s modality firing order of the modalities when selecting the order of techniques, as differing firing orders call for differing treatments. For example, a treatment strategy to support this S-I-C-B firing order (Sensation, Imagery, Cognition, Behavior) may differ from a plan to address an I-S-C-B (or other) firing strategy. Therapists will use deep relaxation to quickly determine a client’s firing order by having them contemplate hypothetical events and describe reactions.
The Process
Through a collaborative setting of goals, the therapist provides rationale for clear, concrete measurable goals based on the client’s BASIC ID and life-history questionnaire. The client must understand and agree on all goals and identify what they are going to do to achieve the desired outcomes/positive changes. Therapists also tailor, monitor and adapt their demeanor and interactions with clients based on the client’s preferred approach (identified in the questionnaire) and personality and to meet the needs of the specific issue being addressed. For example, some clients prefer the therapist to be a directive trainer (Palmer, 1994) where others prefer a warm, genuine relationship. Similarly, some issues require a trainer or educator persona while other issues warrant comfort and empathic listening. In this way, the client helps set and facilitate the therapeutic or training alliance (Palmer & Dryden, 1995).
Therapists also provide role modeling. Clients learn, in part, by observation and imitation of other’s behaviors and since therapist is seen as an expert, it is essential therapist be aware of attitudes, values, beliefs and behaviors. Therapists are also highly flexible and versatile as well as knowledgeable and skilled in several specific techniques and relationship styles for specific problems. Therapists are always correlating responses, interactions and techniques with client’s goals and in this way are seen as “authentic chameleons” (Lazarus as cited in Corey, 2005).
A painstaking effort is made to ensure a precise match between the specific problem and the techniques and relationship used in order to effectively blend relational approach and techniques most suitable for specific client and client problem. Therapy proceeds this way because multimodal therapists believe maladaptive functioning stems from missing and misinformation and response patterns that become conditioned in a maladaptive order.
Personality is seen as complex and multi-factorial and individuals are considered diversified and unique. Thus a treatment plan must also be also multifaceted and unimitable. Humans are seen as individual with individual problems within their own unique context (environment) thus a breadth of skills needs to be taught using specific treatments for each specific problem across all modalities. Technical eclecticism addresses maladaptive functioning in all modalities (domains of personality), with specific (clinically and empirically) supported treatments (technique and relational style) for each specific client and client problem within the individual client’s environment in order to ensure the most effective outcome. Change is believed to occur through learning coping and functional life skills in therapy that are directly related to specific problems in specific areas of a client’s specific context that can then be applied to all future problems. MMT has high prescriptive efficacy as its process is indicative of its theory of (human) functioning and its treatment modality and framework are supportive of its theory of change.
The “Problem”
Janet is both the product and producer of her current environment. Her thoughts, feelings and actions and the order in which she experiences these in response to her environment, in relation to those modeled by her parents and exhibited by her husband, children and community groups, contribute to and serve to maintain her current state of lethargy, social withdrawal, poor sleep and feelings of loneliness and resentment, and loss of identity.
Janet’s parents valued high achievement (they owned both real estate and hotels) and independence (they were entrepreneurs). Janet learned to associate high achievement (behavior/action) with a high sense of self-efficacy (belief in what makes me worthwhile) and feelings of self-worth. The social consciousness of the German individualistic society in which she (collected from the client’s life history inventory) was raised (and that contributed to her parents’ provision of a stoic versus communal home environment) also facilitated Janet’s faulty thinking that “I am worthwhile and personally satisfied only to the degree that I am actively productive in my life”. Although further information regarding the actual familial and social mileu would be provided from the lifestyle history inventory, I am hypothesizing that Janet’s parents modeled a closed approach to discussions regarding and displays of affect.
Being a wife, mother and active community member are behavioral avenues Janet has taken in line with this way of thinking. She maintained a high level of achievement, influencing her interpersonal relationships (high degree of involvement in her daughter’s life) and social relationships/environment (church group; United Way), which created a (perceived) high level of expectation and reliance on the maintenance of that relationship pattern. Prior to the changes in her environment (relationships; social involvement), Janet’s actions, environment (i.e., relationships; community), and intrapersonal states (affective; physiological) were congruent with her beliefs and she was therefore able to maintain an intact sense of self (through high sense of self-efficacy), experiencing no disruption in functioning.
Janet’s divorce, children leaving the home, daughter having her own independence and identity, and cessation in community involvement, has left Janet without any perceived present or future avenues for achievement. This has caused disruptions in her BASIC ID (7 modalities of functioning; behavior, affect, sensation, images, cognitive, interpersonal relationships, and drugs/biological). Her perceived underachievement creates cognitive dissonance (incongruence between her belief that she must be actively productive and her current inactivity), which leads to a lowered sense of self-efficacy, which leads to a negative emotional (loneliness) and physiological reaction, which leads to a behavioral response (social withdrawal) and negative physiological functioning (poor sleep). Because the emotional or affective responses are difficult to address (as both a reactive response to the inherent aversiveness of negative affect and a learnt behavior from her stoic childhood familial environment), Janet’s overt response is defensiveness (expressions of resentment), avoidance (reflections of the underlying issues: Hurt and loss of relationship and identity) through blaming others for her issues (behaviors; negative affect) and engaging in dogmatic preferences (“I should have done something for myself”).
Janet’s firing order (Cognitive-Behvavior-Affect-Sensation) is a learnt (via modeling) and reinforced and repeated through her life choices and relationships. The maladaptive functioning that results from the misinformation that self-worth is measured by achievement and the missing information that she is contributing to her own underachievement (via faulty thinking and social withdrawal) can be made apparent to Janet by creating a modality profile. This profile will identify the specific areas of concern for Janet within each modality (personality domain) and identify specific treatments that are the most likely to be effective (i.e., empirically and clinically supported) for each. For example, this will help Janet set a concrete goal to reconstruct her faulty thinking (cognitive modality) which will in turn empower her to see that she can change her own behaviors (i.e., re-engaging in church groups and United Way) and overall environment (i.e., interpersonal relationships), which will lead to a decrease in negative affect and sleep dysfunction. Janet will be able to achieve and maintain healthy functioning (in this modality - issues in the other 6 modalities are targeted as per the modality profile) by applying the learnt coping, cognitive and behavioral strategies in therapy (i.e., cognitive restructuring; relaxation; therapist modeling) to future life circumstances/events.
Treatment Plan
I would conduct a comprehensive assessment of Janet’s BASIC ID and use the information she provides me with from the Life History Inventory to understand the cognitive connections between the 7 modalities (of the BASIC ID) and track her firing order to create, collaboratively with Janet, a modality profile (see Table Example 1). I would identify specific proven treatments (drawn from the counselling model that best addresses Janet’s needs) for each issue within each modality, ensuring that Janet is in agreement with each specific goal by having her identify the specific actions she is going to take/engage in, in order to meet each goal.
TABLE EXAMPLE 1
Modality Profile for Janet
(adapted from Lazarus, 1973)
Modality |
Problem |
Proposed Treatment |
Behavior |
Social withdrawal Frequent crying Poor sleep |
Re-engage with the church group once per week Non-reinforcement Pharmacological intervention (i.e., sleeping pill) and relaxation yoga nightly, 15 minutes prior to bedtime |
Affect |
Loneliness Bitterness/resentment |
General relationship building Empty chair and behavior rehearsal |
Sensation |
Lethargy |
Exercise regime (i.e., daily 15 minute walk in the neighborhood) |
Imagery |
Bleak outlook of future |
|
Cognition |
Faulty thinking: “Achievement is defined only through my overt involvement and contributions to others” Irrational beliefs: “I am worthwhile only when I am actively productive in my life” |
Cognitive restructuring: Disputing irrational beliefs and challenging faulty thinking |
Interpersonal Relationships |
Dependency upon others for sense of self-efficacy and achievement |
Specific self-sufficiency assignments (i.e., complete one self-care task per day; create an achievable weekly “to do” list and check off all completed tasks) |
I would tailor my relationship approach with Janet to reflect both her identified (in the inventory) preference and to best support her specific issues (i.e., psychoeducational and teaching for missing cognitive information; empathetic listening for discussions regarding affect).
I would begin treatment by focusing on addressing issues in the modality that Janet is presently in (demonstrated by her willingness to engage in discussions), which is cognitive in this case, and use bridging questions and relationship styles to merge to modalities that Janet display adverse reactions to (i.e., affect), demonstrated by her avoidance and defensiveness of the modality.
I would then implore Janet to maintain healthy functioning by applying the strategies (coping, cognitive, relaxation, etc.) learnt in therapy to other issues (i.e., minor issues not addressed in therapy) and future concerns.
Outcomes: Evaluative Element and Common Factors
MMT is theoretically grounded in social learning and cognitive theories, which are well documented and empirically supported (e.g., Bandura, 1977; Rotter, 1954). MMT postulates that human behavior is learnt (through modeling), reinforced and produced through interactions with the social, interpersonal and intrapersonal environment. Therefore change is effected by an individual through those same environmental factors within an individuals’ specific life context. This construct (origin of behavior and process of change) fit the intuitive test and easy to operationalize. However, because MMT is technically eclectic, testing the construct can be difficult in that each treatment plan is unique to the client and thus difficult to replicate. Nonetheless, outcome studies on MMT have proven to yield high positive outcomes and maintenance of therapy benefits (Kwee, Duivenvoorden, Trijsburg, & Thiel, 1986; Kwee & Kwee-Taams,1994; Kertész, 1986; Williams,1988).
Asay and Lambert (1999) asserted that four therapeutic factors account for the percentage of improvement in psychotherapy: Extra-therapeutic effects (40%), therapeutic relationship (30%), expectancy/placebo effects (15%), and techniques (15%). MMT capitalizes on common factors to facilitate successful counselling outcomes. The MMT framework uses the BASIC ID and life history inventory to understand client factors including personal and social history, description of presenting problems, the cognitive links between the modalities (personality domains within the BASIC ID), and preference for treatment approach. Through this framework, MMT also considers extra-therapeutic effects such as antecedents, current problems and maintaining factors of the problems in designing the treatment plan. MMT uses techniques such as homework and specific self-sufficiency assignments to facilitate change in the clients’ natural environment (outside of therapy). Additionally, MMT’s goal of therapy is founded on the belief that humans are the product and the producer of their own environment, which directly assumes that extra-therapeutic effects are the major factor in client change.
Therapeutic MMT techniques (i.e., modeling; relaxation; lifestyle changes) are the vehicle through which clients learn adaptive and coping skills. The expectation (client and therapist) and practice of direct application of these learnt strategies to the functioning of the client in the real world (the client’s individual context) is what ensures successful (therapy) outcomes. Moreover, through using a technically eclectic approach, all maladaptive functioning in the client’s natural environment is addressed through a multitude of empirically and clinically supported specific techniques.
The treatment plan is based on the individual client in their unique context, in absolute collaboration with the client: Goals are set only with the clients’ commitment to design and implement actions in support of their own goals. Therapists also tailor their relationship styles to meet the specific needs of the individual client and adapt their style as those needs change.
Although some of the literature on MMT cited in this paper – and according to The Lazarus Institute – includes the identification of client strengths within the BASIC ID, this model largely operates from a deficit based approach and thus does not make full utilization of the client factor (strengths).
Because MMT capitalizes on common factors and has a relatively stable theoretical evaluative component, is likely to prove one of the most beneficial therapies in promoting client progress because it
helps the therapist adopt a different way to identify or approach the client’s goals, establish a better match with the clients’ stage of change, foster hope, capitalize on chance events and clients’ strengths, and to make use of or [help the client] become aware of environmental supports (Hubble, Barry, Duncan & Miller, 1999, p. 424).
Personal Learning
It is not enough – and is rather unethical – to base therapeutic interventions on wanting to support the best interest of the client: I must ensure it. I did not begin this paper with the naïve notion that I can help just because I care. I also did not begin this course with believing that psychotherapy is a science. However, understanding that a sound theoretical orientation will guide the therapeutic process by helping me choose empirically and clinically supported techniques that will effectively address specific client problems, serves to further facilitate my ability as a therapist to recognize and capitalize on common factors to ensure – to the best of my ability – positive client change.
When I began writing this paper, I held only minor interest in being married to one theoretical approach and using a therapeutic technique based on its empirical support. But I now comprehend that the theory guides my understanding of what factors contribute to maladaptive human functioning (i.e, view of human nature), what serves to maintain that dysfunction and what the necessary components are to effect positive change in that level of functioning. Common factors (i.e., client factors; extra-therapeutic effects; techniques; expectancy/placebo effects; therapeutic alliance) have to be understood within the context of human functioning - and specifically within each clients’ individual environment – in order to know how to facilitate a therapeutic (versus benign or harmful) process.
Of course caring and genuine compassion are significant elements of the therapeutic process (i.e., therapeutic relationship), as “the quality of the counselling relationship has consistently been found to have the most significant impact on successful client outcomes” (Whiston as cited in Jennings & Skovholt, 1999, p. 3). However, as identified by Jennings & Skovholt (1999), these traits are only a part of the cognitive, emotional, and relational characteristics that deem one a master helper. Voracious comprehension of the human experience, continuous learning of specific techniques that will best support specific client change within a subjective and unique context, the ability to monitor and adapt my relational style and assess personal biases, and maintain my own personal well-being (i.e., relationships; mental health; life functioning) for each client-therapist encounter, are all necessary in order to facilitate positive therapeutic outcomes.
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