Addiction A-Z

Multimodal therapy

Human beings are complex, multifaceted creatures.  And, as such, our problems are almost always multifaceted as well.  When therapists take this into consideration, psychotherapy is more likely to be effective and lasting.  That’s not to say that therapies that focus primarily on one aspect of human nature (e.g. interpersonal relationships, cognitions, or behavior) can’t be helpful.  However, when the benefits of psychotherapy are only short-lived, one of the most likely reasons is that the focus was too narrow.

Dr. Arnold Lazarus, one of the most brilliant psychologists of the 20th century, developed a comprehensive form of therapy several decades ago to address the multidimensional or “multimodal” nature of people.  He named it multimodal therapy.

Often referred to as simply MMT, multimodal therapy is an eclectic form of psychotherapy.  Eclectic therapies draw from and integrate elements of several disciplines, psychology theories, or therapeutic approaches.  It’s important to note, however, that MMT is technically eclectic but not theoretically eclectic.  In other words, the primary underlying theory on which MMT is based is social and cognitive learning theory.  It’s the techniques and strategies used in treatment that are eclectic in nature.

Originally a behavior therapist and pioneer in the area of cognitive behavioral therapy (CBT), Lazarus noted that far too many patients treated with traditional CBT for depression, anxiety disorders, and other issues ended up relapsing at some point.  He believed that the reason for this was that the therapy they’d received wasn’t comprehensive enough.  It had missed some distinct key area that was playing a role in their dysfunction or problem, leaving them vulnerable once treatment ended. They had been treated with what he called “narrow band” therapy, when what they really needed was a “broad-spectrum” treatment approach.

In order to address this inadequacy in other types of psychotherapy – and to ensure a more comprehensive and effective approach to treatment – Lazarus came up with the BASIC I.D.  This concept plays a central role in multimodal therapy.

The BASIC I.D.

Multimodal therapy is based on the premise that seven distinct but interrelated dimensions or “modalities” of psychological functioning, temperament, and personality are assessed and addressed in therapy.  These have come to be known by the acronym “BASIC ID”.   These 7 modalities are:

  • Behavior
  • Affect
  • Sensation
  • Imagery
  • Cognition
  • Interpersonal
  • Drugs/Health/Biology

Behavior represents everything a person does – actions, habits, gestures, etc.  Behaviors can be healthy or unhealthy, destructive or constructive, moral or immoral, mature or childish, appropriate or inappropriate, law-abiding or illegal, compulsive, impulsive, or controlled, and so on.  Many people seek therapy to change unwanted behaviors that are causing problems in their life such as overeating, nail-biting, hoarding, acting out, self-mutilating, or drinking excessively. Traditional behavior therapy focuses on changing the behavior itself with the use of techniques such as modeling, aversive conditioning, and systematic desensitization.  Unfortunately, practically every unwanted behavior is connected to and interacting with other modalities as well, such as emotion, sensation, and cognition. When those aren’t addressed as well, relapse often occurs.

Affect essentially refers to a person’s feelings or emotions, such as happiness, sadness, anger, fear, frustration, and boredom.  One of the main reasons people seek therapy is because they don’t like the way they feel.  For example, depression and anxiety are two of the most common psychological problems for which people take medication or talk to a therapist. Even those who seek therapy for other reasons – e.g. to lose weight, save their marriage, or overcome a phobia – the underlying motivation is almost always to change the way they feel emotionally.  Most individuals who want to lose weight want to feel happier about their body and in general, while those struggling to save their marriage are often motivated by anxiety (the uncertainty of life without their spouse) and the sadness that often accompanies such a loss.

Sensation pertains to our senses – sight, hearing, touch, taste, and smell – and all of our physiological experiences.  Examples of sensations include muscle tension, knots in the stomach, “butterflies”, physical pain, racing heart, tension headaches, cold hands, crawling skin, shortness of breath, sweating, and nausea.  Hallucinations and illusions are also examples of sensations.

Sensation is one of the modalities that is most often neglected in psychotherapy, even though an unpleasant sensation can be very troubling.  Sensations can provide a lot of valuable information in therapy.  For example, unresolved trauma often manifests in psychosomatic symptoms that may be misinterpreted by the client, leading him or her to seek medical treatment instead.  Also, many individuals attempt to address uncomfortable sensations with medication or other substances (e.g. alcohol or drugs).

Imagery refers to the mental images and pictures people create in their mind – in other words, what they visualize fantasize, and daydream about.  A person’s self-image would fall into this category. Individuals who struggle with anxiety often feed their anxiety with exaggerated, fearful images of things that might happen in the future.  People with depression often paint very negative, distorted pictures in their mind.  Those battling eating disorders have distorted body images that play a significant role in their disorders.  Learning to adjust one’s mental imagery can go a long way towards bringing about desired changes.

Cognition refers to thoughts (and thought patterns), beliefs, attitudes, and judgments.  Negative thoughts, including negative “self-talk” and limiting or distorted beliefs almost always play a significant role in depression, anxiety, and other disorders.  Deeply ingrained beliefs about not being worthy or deserving, for example, can undermine a person’s relationships and level of success in life if those beliefs are never effectively addressed.

Interpersonal refers to people’s relationships with others, as well as their social skills – i.e., how they relate to and interact with people in general. It also includes their support system, or lack thereof.  The ability to develop healthy and satisfying relationships, and to feel connected with others, is a key element of good mental health.  Many people seek therapy to address relationship issues, such as coping with a breakup or resolving conflict with a loved one.  Others seek therapy because they’ve become isolated or feel disconnected.  Interpersonal issues are almost always closely tied to cognition and affect.

Drugs, health, and biology go together to form the seventh modality.  This modality encompasses several things, including physical health (e.g. illness, health conditions, physical limitations, age-related health issues, chronic pain), biological factors (e.g. brain chemistry or genetics), and the need for medication or other forms of medical / biological treatment.  Also included in this modality are lifestyle habits that impact one’s health, such as exercise (or lack thereof), diet and nutrition, sleep habits, overeating, drug and alcohol use, smoking habits, etc.

In multimodal therapy, these seven modalities are assessed by the therapist in two ways – by interviewing the client and by having him or her complete a questionnaire known as the Multimodal Life History Inventory.

Multimodal Life History Inventory

This inventory is usually completed by the client at home following the initial session.  It is 15 pages long and includes the following sections:

General Information – This section includes name, address, date of birth, marital status, current and past employment, living situation, etc.  It also asks about personal and family history of suicide attempts, as well as any family history of mental health problems.

Personal and Social History  – In addition to basic questions about parents and siblings, this section also asks about parents personalities, attitudes, and methods of punishment, the client’s relationship with both parents, home environment growing up, education (including scholastic strengths and weaknesses), and issues that occurred during childhood (e.g. bullying, sexual abuse, drug use, medical issues, lack of friends, etc.).

Description of Presenting Problem – This section asks the client to describe his or her main problems, degree of severity, when they started, what the client has tried, etc.

Expectations Regarding Therapy – This section asks the client to write down what he or she thinks about therapy, including how long it should last and what traits an ideal therapist should have.

Modality Analysis of Current Problems – This section allows the client to provide more in depth information about the problems that led him or her to treatment.  It covers the 7 modalities in the BASIC I.D. with a combination of questions, fill-in-the-blank statements, rating scales, and / or checklists for each modality.  This is the longest section of the questionnaire, and is quite thorough in its scope.

The final page of the inventory allows the client to describe any significant experiences or memories (from childhood or any other time in the person’s life) that he or she feels the therapist should know about.

Once the therapist has assessed the client’s 7 modalities – the BASIC I.D. – he or she will determine the best therapeutic techniques and strategies to address them, starting with whichever modality is the most problematic.

Even though techniques and strategies play an important role in MMT, the relationship between therapist and client is also very important.  Clients list the qualities of the “ideal” therapist (in their eyes) on the inventory.  Multimodal therapists recognize the importance of adjusting their relationship style depending on the client’s needs and preferences (information that can usually be obtained from the inventory).

For example, some clients do much better with a therapist who is very warm, personable, and empathetic.  Others, however, prefer a therapist who maintains a more businesslike demeanor.  Additionally, some clients prefer working with a therapist who is very active and direct, while others prefer a therapist who listens very well and takes a less direct approach.  Tailoring therapy, as well as therapy style, to the client will enhance the positive effects of therapy.

Common Techniques Used in MMT

The techniques and strategies used by the therapist come from many different psychotherapeutic approaches as well as other disciplines, including Gestalt therapy, classic behavior therapy, cognitive therapy, family therapy, psychodrama, Logotherapy, guided imagery, bibliotherapy, anger management, relaxation training, hypnotherapy, biofeedback, and social skills training to name several.  Therapists are encouraged to use techniques that are empirically supported as much as possible.  In some cases, the therapist may need to refer clients to another provider.

Behavior

  • Modelling
  • Self-monitoring
  • Systematic desensitization
  • Reinforcement
  • Contingency contracts
  • Response cost
  • Shame attacking
  • Paradoxical intention
  • Behavior rehearsal

Affect

  • Emotion regulation
  • Anger management
  • Feeling identification
  • Pleasant activity schedule
  • Identify triggers

Sensation

  • Biofeedback
  • Relaxation training
  • Massage therapy
  • Hypnosis
  • Meditation
  • Sensate focus training
  • Yoga

Imagery

  • Mastery imagery
  • Positive imagery
  • Aversive imagery
  • Time projection imagery
  • Thought stopping imagery
  • Coping imagery
  • Anti-future shock imagery

Cognitive

  • Cognitive restructuring
  • Positive self-talk
  • Thought records
  • Disputing irrational beliefs
  • Thought stopping
  • Bibliotherapy

Interpersonal

  • Assertiveness training
  • Social skills training
  • Intimacy training
  • Communication skills training
  • Role reversal
  • Fixed role therapy

Drugs / Health / Biology

  • Exercise
  • Smoking cessation program
  • Weight management
  • Nutrition education
  • Lifestyle changes
  • Consult with physician or other healthcare provider (with client’s permission)
  • Refer to specialists

Disorders, Conditions, and Problems that Can Benefit from MMT

Following are just some of the problems and disorders that may benefit from multimodal therapy:

  • Depression
  • Generalized anxiety disorder
  • PTSD
  • Eating disorders
  • Panic disorder
  • Social anxiety disorder
  • Relationship problems
  • Weight problems
  • Emotional eating
  • Stress management
  • Behavioral issues
  • Compulsive behaviors
  • Low self-esteem
  • Insomnia
  • Chronic pain

Advantages of Multimodal Therapy

While no therapy is perfect, multimodal therapy has many advantages that are worth considering.  These include:

  • Multimodal therapy is a very comprehensive and flexible form of psychotherapy. Its “broad-spectrum” approach to treatment is one of the reasons it’s so highly effective.
  • The thorough assessment that plays a key role in MMT helps ensure a more accurate diagnosis and also helps the therapist select highly focused treatment strategies. Together, these two elements enhance the effectiveness of treatment and increase the likeliness of lasting results.
  • In MMT, treatment is tailored to the client’s needs by using a combination of techniques and strategies from many different therapeutic approaches and disciplines. The therapist carefully chooses the ones that are appropriate for the particular client and likely to be the most effective.  Because the techniques aren’t limited to a specific psychological theory or orientation, the range of potential interventions at the therapist’s disposal is much broader than in other forms of psychotherapy.
  • Multimodal therapy addresses the seven key modalities of personality and functioning, and identifies which ones are the most problematic. This ensures that no modality is overlooked, which would make the client vulnerable to relapse.
  • Multimodal therapy takes into consideration the fact that clients’ problems usually involve an interaction of several modalities rather than just one or two.
  • By assessing a client’s BASIC I.D. and addressing the most problematic areas with appropriate interventions, MMT helps the client make positive changes that align more closely with his or her ideal self.
  • Therapists who use multimodal therapy don’t just customize the techniques and interventions to their clients; they also tailor their therapeutic style to fit the client’s needs – i.e. the client’s individual manner of thinking and feeling. Working with a client in a style that suits him or her naturally enhances the therapeutic relationship, which is a key element of effective therapy.

Multimodal Therapy in Practice

If you’ve read this far, you may still be a bit unsure as to how all the pieces fit together in terms of how MMT actually works.  Following is an example of the way multimodal therapy could be used to address a client who has problems with emotional eating:

  • Behavior: Remove comfort foods from the home and office; make a list of alternative, healthy behaviors you can do when negative feelings arise (e.g. go for a walk, call a friend, or write in a journal), and choose one to do each time you feel tempted to comfort yourself with foods
  • Affect: Use stress management techniques to lower stress; identify emotional triggers that lead to comforting yourself with food – i.e. what feelings (e.g. anger, sadness, boredom) tend to be present when you feel the need to self-soothe with food?
  • Sensation: Use relaxation methods to reduce and manage anxiety
  • Imagery: Visualize yourself handling conflict and other stressors calmly and effectively
  • Cognition: Keep a journal of the negative thoughts that lead to emotional eating (i.e. what are you telling yourself just before you reach for the bag of cookies?); use constructive self-talk when tempted to eat for comfort
  • Interpersonal: Seek support from friends or family when you’re experiencing intense negative emotions; practice assertiveness skills in order to reduce feelings of powerlessness and inferiority that trigger emotional eating
  • Drugs / health / biology: Get some form of exercise each day to help reduce stress; get sufficient sleep so you’re well-rested each day (as fatigue makes negative emotions even worse)

Another example, for someone dealing with depression:

  • Behavior:  Keep a regular sleep schedule; do at least one pleasurable activity a day, even if you don’t feel like it
  • Affect:  Reduce sadness by looking for the joy in small things; express negative emotions in therapy and / or writing in a journal rather than keeping them inside
  • Sensation:  Use yoga or massage therapy to reduce muscle tension
  • Imagery:  Visualize a positive, worthwhile future when bleak images come into your mind
  • Cognition:  Practice positive self-talk; write down negative beliefs that are contributing to feelings of worthlessness and hopelessness; challenge their accuracy
  • Interpersonal:  Avoid isolation by spend more time with people you enjoy or engaging in activities that involve interacting with other people
  • Drugs/ health / biology:  Exercise regularly to boost mood; take antidepressant medication to help alleviate symptoms and improve overall functioning

The interventions used above are just examples of what might be used, but many other interventions and strategies could be used in their place depending on the specific client and his or her BASIC I.D.  The therapist may use entirely different strategies than those above to address the same basic issue with another client, depending on multiple factors.  This is one of the strengths of MMT – it’s not a cookie-cutter / one-size-fits-all approach.  Rather, the treatment is carefully customized to fit the client’s needs, based on the information obtained from the initial interview and the Multimodal Life History Inventory.

Contraindications for Multimodal Therapy

There are certainly times when MMT isn’t the best or most appropriate approach for clients.  For example, individuals who are psychotic, actively suicidal or manic aren’t going to be appropriate for this treatment approach. For starters, they require an intensive crisis intervention that focuses on safety and stabilization first and foremost.  It would also be impossible, or at least extremely difficult, for such individuals to complete the Multimodal Life History Inventory, since doing so requires the ability to sit still, focus, and think clearly. Multimodal therapy is generally contraindicated for anyone with a severe psychiatric disorder or in an acute crisis.

Another contraindication for MMT is active substance abuse.  It can be effectively used for individuals who are in recovery, either as part of a dual diagnosis treatment program (in which mental health issues and substance abuse or addiction are treated simultaneously) or following drug and alcohol treatment when the patient is clean and sober.  However, when someone is actively using alcohol and drugs, psychotherapy of any kind will have very limited – if any – benefit.

Brief History of Arnold Lazarus and Multimodal Therapy

Arnold Lazarus (1932 – 2013) was a clinical psychologist, professor, prolific author, and popular lecturer.  A native of Johannesburg, South Africa, he completed his undergraduate and graduate training at the University of Witwatersrand in Johannesburg.  He eventually moved to the U.S. and became a prominent figure in the modern psychology movement.  Credited with coining the term “behavior therapy”, Lazarus also made significant contributions in the areas of eclectic therapy and cognitive behavioral therapy.  He was awarded several honors for his brilliant work, including the American Psychological Association’s prestigious Distinguished Psychologist Award of the Division of Psychotherapy.

He developed Multimodal Therapy after noticing limitations with CBT.  He had reviewed the outcomes of multiple patients who had received this particular therapy and found an unusually high relapse rate.  He believed that this was due to the therapy’s failure to address one or more key dimensions or modalities that all humans inherently possessed (the BASIC I.D.).   Part of his approach to developing MMT involved asking therapy clients what aspects of therapy had been beneficial to them.  In 1976 he founded the first Multimodal Therapy Institute, located in Kingston, New Jersey.  He went on to set up additional Multimodal Therapy Institutes in 6 other states.

Over the years, Lazarus wrote several hundred articles as well as multiple books.  Some of his books are geared primarily towards clinicians.  However, he also wrote several popular self-help books targeting the lay reader interested in improving his or her life. His books include Behavior Therapy and Beyond (1971), I Can If I Want To (1975, with Allen Fay), In the Mind’s Eye: The Power of Imagery for Personal Enrichment (1977), The Practice of Multimodal Therapy: Systematic, Comprehensive, and Effective Psychotherapy (1981), Mind Power: Getting What You Want Through Mental Training (1987, with Bernie Zilbergeld) Don’t Believe it for a Minute!: Forty Toxic Ideas that are Driving You Crazy (1993, with Clifford N. Lazarus and Allen Fay), The 60-Second Shrink: 101 Strategies for Staying Sane in a Crazy World (2000, with Clifford N. Lazarus), Marital Myths Revisited: A Fresh Look at Two Dozen Mistaken Beliefs About Marriage (2001), and Brief But Comprehensive Psychotherapy: The Multimodal Way (2003).  

Finding a Multimodal Therapist

While multimodal therapy is an excellent treatment approach for a variety of psychological problems and life challenges, finding a therapist who practices Lazarus’ approach may not be so easy.  Many treatment programs are “multimodal” in nature, but the term doesn’t necessarily refer to this specific psychotherapy.  Multimodal may simply mean that the  program address the patient’s physical, mental, and spiritual health, or that it uses a variety of treatment modalities to address the patient’s needs.

Finding a therapist who uses Lazarus’ approach will likely require some digging unless you live in a large metropolitan area.  You can search online for “multimodal therapy” or “multimodal psychotherapy” followed by the name of your city.  Your search results will likely be mixed, with several that aren’t specific to this form of therapy.  However, you may find a therapist or two who specifically states that he or she practices this type of therapy.  If you do find any experienced multimodal therapists in your area, it’s certainly worth contacting them to get more information and determine if one of them is a good fit for you.

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