Some Notes On Multi-modal Behavior Therapy

George W. Doherty, M.S.

Multi-modal behavior involves the following:

1. Specification of goals and problems.

2. Specification of treatment techniques to achieve these goals and remediate these problems.

3. Systematic measurement of the relative success of these techniques.

Cognitive restructuring and overt behavior training are often reciprocal. Behavior change must occur before "insight" can develop.

Those therapists who favor working with one or two specific modalities might ask what evidence there is to support the contention that multi-modal treatment is necessary. There are studies which have shown that relapse all too commonly follows after many behavior therapy programs. This seems to happen despite the fact that behavioral treatments usually cover more modalities than most other forms of therapy. Most therapists, however, do not devote as much attention to imagery as is advocated here. This is true even when using covert reinforcement procedures and imaginal desensitization. Most behavior therapists don't get too involved with cognitive material. They tend to neglect various philosophical values and their impact on self-worth.

It is worth emphasizing that in attempting to offset "future shock", multi-modal therapy tries to anticipate areas of stress which the client is likely to experience in the future. Therefore, one may use imaginal rehearsal to help prepare people to cope with the marriage of a child, a possible change in career or occupation, the purchase of a new home, the process of aging, the aftermath of a disaster, etc. Such psychological "drills" can serve important preventative functions.

As the therapist investigates each modality with a client, a clear understanding of the individual and his/her interpersonal context emerges. For example, even with a simple phobia, unexpected information is often gained while examining the behavioral, affective, sensory, imaginal, cognitive and interpersonal consequences of avoidance responses. When a level or plateau is reached in therapy and progress slows, it might be useful and productive to examine each modality in turn to identify possible neglected areas of concern. Quite often new material comes out and the therapy proceeds with it.

Multi-modal behavior therapy emphasizes the need to directly attend to the correction of deviant behaviors, unpleasant feelings, negative sensations, intrusive images, irrational beliefs, stressful relationships, and possible chemical imbalance. For example, in treating depressed persons, especially those who may be suicidal, it is essential to get the client to recognize and use a variety of reinforcers. Long lasting, durable results call for a whole new range of interpersonal skills, the elimination of self-deprecation, time-projected images in which the client sees him/herself taking part in future rewarding activities, a "sensate focus" of pleasant, enjoyable events, a repertoire of adaptive affective responses, and a behavioral pattern which is characterized by daily sampling of personally reinforcing activities.

A cognitive mediational model of affective responses suggests therapeutic strategies different from those derived from a non-mediational or classical conditioning paradigm of aberrant behavior. The causes of traumatic neuroses are not necessarily paradigmatic of neurotic disorders generally. Clinical observations seem to suggest that most deviant responses are acquired by processes of verbal communication, modeling and imatation, not by traumatic or sub-traumatic classical conditioning. Using methods of "cognitive restructuring" rather than "systematic desensitization" to treat phobic conditions, for example, can sharply reduce the mean number of sessions required to overcome a phobia.

Whereas psychoanalytic theory overlooks conditioned avoidance phobias, behaviorists tend to overlook the role of unconscious conflicts in the causes of other phobias. It is necessary to assess the severity, degree of incapacitation and the secondary gains of phobias and phobic behavior. Phobias may be symbolic responses and serve as aggressive weapons or manipulative devices. Treatment of phobias necessitates a full appreciation of the sensory and cognitive learning involved. It is also necessary to distinguish between fear, anxiety phobia, and conditioned avoidance in order for treatment to be successful.

Psychotherapists who function as eclectic theorists must inevitably embrace contradictory notions. Remaining theoretically consistent doesn't require rejection of promising techniques which might originate within other theoretical orientations. A practitioner's range of therapeutic effectiveness can be enriched through technical eclecticism. This does not have to violate one's allegiance to any particular theoretical system. Therapeutic competence depends on an array of effective techniques rather than on a mass of plausible theories. Psychotherapy as an art must be distinguished from the science of psychological investigation. A therapist who is theory-bound is likely to be too inclined to subordinate observed facts to a priori assumptions. Technical eclecticism can permit a clinician to apply empirically effective methods prior to scientists identifying reasons for their effectiveness.

Most therapies help at some times. Therefore, the best approach would be to utilize all methods when necessary. BASIC ID is an acronym for a therapy devised by Arnold Lazarus dealing with Behavior, Affect, Sensations, Imagery, and Cognitions in Interpersonal Relations using Drugs when helpful. This involves a rationale for recommending direct intervention over seven distinct but inter- related modalities.

Behavioral norms might suggest new methods of intervention. They may be particularly helpful when deciding if intervention is appropriate at all. They might also be crucial in the development of maintenance and generalization strategies for non- treatment environments. The usefulness of behavioral norms is demonstrated thru the answers to the questions below:

Does the problem exist?

When clients are referred, it's generally assumed that some problem exists. Otherwise they would not have been referred. The therapist typically obtains baseline data to determine the frequency of problem behaviors. However, these data are rarely compared with the frequency of such behaviors among those who are not referred.

Is the problem specific to time or place?

Information about non-problem situations may suggest different interventions for the problem situation. There isn't much knowledge currently available about how behaviors vary over daily or weekly periods. This knowledge would be very useful to help decide the "if", "how" and "when" questions of intervention.

Will improvement occur without intervention?

This is the most crucial question to be answered prior to implementing any intervention strategy. The exception may be the persistence of behavior problems. Duration of a problem must be considered prior to treatment.

Whether intervention is necessary is dependent upon the nature of the problem. For example, intervention for the anti-social behavior of children might be more critical than for other problems.

Intervention for which behavior by whom?

If normative data for peers, parents, teachers and settings is available, it provides a greater variety of possible intervention strategies. Normative data on activities of persons who are neither clients nor criminals can be used to develop measures of psychosocial functioning and strategies for generalization maintenance.

There are four basic conditions which facilitate systematic processing of information in therapy:

1. Assessment should yield direct implications for treatment.

2. Therapeutic objectives should be specified in measurable terms.

3. Therapeutic techniques should be specified for each objective. These techniques must be recognizable and replicable.

4. The process and outcome of therapy should both be evaluated.

Evaluation should occur within each modality and should be of three different varieties:

1. Evaluation of implementation is concerned with the adequacy of the application of each therapeutic strategy. It is aimed at determining the extent to which therapeutic techniques are appropriately administered and efficiently adapted.

2. Evaluation of progress involves the inspection of the degree to which therapy is producing movement in the direction of each stated objective. The progress of therapy is evaluated periodically and systematically in relation to the diagnosis, objectives and techniques. In such a way, many implications for corrective action may be generated.

3. Evaluation of outcome occurs at the termination of therapy. It provides an answer to the question: "To what extent were the therapeutic objectives accomplished?"



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