Multi-Modal Treatment of the Client\'s

¶ … multi-modal treatment of the client's mental problems. If the root of the problem is found in early childhood, and has expressed itself then or later, in an adult, then the author may treat the condition with the techniques of Egan, Hutchens or other cognitive-behavioral theories, chosing elements from them to bring the client back to a healthy state of mind. An analysis of Egan's theory, Hutchens' theory, and a brief overview of most of today's cognitive-behavioral theories are reviewed in this paper. The author displays his own preferences for how he will approach the client-therapist relationship.

Personal Theory of Psychotherapy

Multimodal Therapy involves technical eclecticism, or the belief that treatment should consist of techniques from many schools of psychotherapy, without the psychotherapist necessarily having to declare his or her adherence solely to the theories of any one of those techniques. Multimodal therapists utilize flexibility of technique selection. They are, however, expected to be familiar with, be current on and consult current research. They must favor research-backed techniques over techniques without research backing. The multimodal therapist also tailors treatment to the needs of the individual being treated (Wikipedia 2006). In this regard, the favored client-therapist mode of relationship would have to be as a mentor and caring guide, as those who adhere to the cognitive-behavior therapy believe it should be.

Multimodal Therapy is an approach to psychotherapy founded by Arnold Lazarus. Based on the idea that human beings are also biological beings that can think, feel, act, sense, imagine, and interact; and that each of these can be addressed in psychotherapy. Multimodal assessment and treatment is built around the BASIC ID framework. ("BASIC ID" is an acronym, which stands for "Behavior, Affect, Sensation, Imagery, Cognition, Interpersonal, and Drugs/biology") (Wikipedia 2006). This is the overall approach that incorporates people-centered therapy, Gestalt, Cognitive-Behavioral and Reality therapies, among others.

Each psychotherapist's approach to counseling is an eclectic mix of several different styles. However, the Egan model of counseling utilizes several different schools of thought and appears to be a model for the contemporary counselor. Arnold Lazarus' theory of counseling also holds valuable tools from several different sources and used as a source, as well. As one who may also approach a patient who expects it to be a part of the therapy, the Christian counseling approach may be used for a client who seeks a "Christian" counselor. The therapist then can integrate his or her knowledge of psychology and theology to best treat the client. Some clients may feel comfortable just knowing their counselor is a Christian, feeling their advice can be trusted. Some clients wish to use the Bible as a reference for therapy. For some, prayer may enter into the process as well (Christian Counselors 1).

Some patients find it easier to deal with mental health issues as part of a larger spiritual problem, believing it is more acceptable to have spiritual problems than to be labeled as a "mental health" patient. Faith based therapy requires slightly more emotional input from counselors than some other modes of therapy and points of theology may interfere with planning strategies, when faiths or texts disagree. Still, if the client can relate on a faith level and find inspiration in the examples in the scriptures, then this kind of therapy may find more acceptance and therefore effect a faster positive result than other modes of therapy, when dealing with this state of mind.

The patient approaches therapy with what is considered an "unhealthy" mental or emotional state of mind. Freud believed that all neuroses were rooted in childhood sexual abuse (seduction), that a child moves from Eros through Thanatos, from one stage to the next, developing the super-ego, as he or she grew. Others, including, his own daughter, Anna Freud, and her contemporary, Melanie Klein, disputed the belief that there were stages that one passed through and to which one could not return (Freud, 1905). By doing research in play therapy, they noted there were positions into which children moved, then returned. Children went back and forth from one "position" to another, "progressing," but returning to earlier stages as well. Klein believed that children who were ill were (and remained) in the "depressive" position. These depressed children either withdrew, or expressed anxieties and aggressive fantasies that later were acted out on other, weaker or submissive members of the society they found around them when the super-ego did not restrain them. (Freud 1966) as they remained in the depressive position, great feelings of guilt over their attitudes towards their mothers or fathers are suppressed and remain with them throughout their adult life, surfacing only at times. In Sigmund Freud's analysis, most humans have this guilt and shame, but if abused or if there is a traumatic event as a child, the reaction to the event becomes a neurosis in the adult.

A counselor's first communication with the patient involves some kind of preliminary searching and analysis in the first stage of therapy. The counselor may need to determine how the patient communicates, and how the client approaches life. If the client exhibits psychotic reactions, then a different analysis and way of dealing with the past may be in order. If the patient has difficulties with anxieties and in functioning socially, the counselor may approach the patient on a whole different level, as a behavioral-cognitive therapist with reality, Gestalt and Egan's Problem Management Opportunity Development approaches. Mentoring to help the patient develop a positive frame of mind through exercises and "homework" is a part of the therapist's repertoire.

Egan's model problem management approaches involve communication skills. These skills may incorporate basic and advanced empathy, probing and challenging skills, as well as client-centered treatment planning. The Egan model can be used in many different situations, some of which have nothing to do with mentoring at all. The Egan model is generally the most effective when the client is addressed with respect, empathy and, of course, active listening.

Hutchens believes that not only is therapy a corrective emotional experience, but that it is an educational experience for both the client and therapist, and that once the counselor is able to identify what will be the best approach to the patient, he or she will be able to use every skill at his or her command to help the client meet therapy goals.

In person-centered therapy, the individual is seen as a self-determining agent responsible for the authenticity of his or her choices. The therapeutic goals are knowledge of oneself and movement toward self-directedness and balance with the support of one's therapist, who has developed a close, personal relationship with the client. This ties in with Hutchens' thinking that the experience is education, but not with Ellis' belief that the therapist must correct the client's false impressions of the way the world works. While the client determines the general direction that therapy will take, the therapist adds insight and clarification through questions put to the client that will bring him or her to awareness of self. (Rogers, 1951)

Rogers focuses on the human potential, defining human nature as inherently good and seeking one's fullest potential in life. However, unconditional regard for the client has the therapist going through the therapy with the client, rather than as a guide. The client can express him or herself without worrying about what the therapist thinks of him or her or whether they did right or wrong, as the therapist does not seek to change the client's way of thinking, even if negative expressions are made.

Gestalt therapy takes into account the whole person, including thoughts, feelings, behavior, body sensations, and dreams. The focus is on integration, how the many parts of the person fit together, and how the client interacts with the environment. (VanBuren, 2003, 1) the techniques used in Gestalt therapy vary as widely as there are therapists and clients, from principles based on Holism, Field theory, figure formation, organismic, the concept of the Now and "unfinished business." The therapist dialogues with warmth and caring, yet remains "invisible," in the role of onlooker, as the client is encouraged to interact with the environment, which is very similar to the way the therapist acts in person-centered therapy.

Results of contemporary research are important in determining if a therapy would be successful with a particular client and therapists are encouraged to only use those methods which have been tested. However, Postmodern Therapy does not utilize the results of tests, but is based on individuals simply discovering meaning for themselves in sessions with their therapists through unorthodox and sometimes untested methods. Postmodernists believe that research statistics are worthless when it comes to the practical side, that of personal interaction with one's own relevance to human experience (Simon, 1994, p. 203).

Multimodal therapy involves a complete assessment of the individual and treatments designed specifically for that individual. Arnold Lazarus developed this approach, in part, by questioning clients about the factors that had helped them in their therapy. Lazarus describes human functioning in terms of seven modalities, of which, because of limited space, shall not be able to be examined in full. Self-management is the goal of the client and the therapist works with the client to aid him or her in recognizing self-defeating thoughts or actions that will give negative results, and developing positive thoughts that will have positive results (Lazarus, 1997).

The first tenet that is examined is the one Lazarus calls "Positive Thinking."

Positive cognition is focusing on personal skills and strengths, on what is good in the world, believing in one's self and belief in one's ability to succeed. When this is the dominating thought, the client then acts in ways that bring him or her closer to success. Positive thoughts and images about one's abilities dramatically increase one's chances of succeeding. Believing that success is possible is a prerequisite for most achievements.

Thinking positively does not mean being unrealistically optimistic. Nor does it mean one is without limits, that others will only help and never hinder, or that society has no negative aspects. Problems and setbacks arise as goals are pursued, but watching for them and learning how to overcome them helps one avoid them, or at least to cope better. Positive thinking must be realistic in order to continue to exist.

Lazarus then brings up the obvious opposite: "Negative Thinking" or negative cognition.

Negative cognition means focusing on liabilities and weaknesses, problems and what is bad in other people and the world around us. By dwelling on the negative one develops a cynical attitude that can be quite debilitating. As one searches for gloom and doom, defeat and failure, one is usually successful in finding them.

Negative thinkers have good reason to believe the world is against them because if they think they are failures, they become a failure. To believe victory is unattainable and defeat is imminent often results in stress and self-defeating behaviors.

Existential Therapy is also compatible with the development of optimism, making good choices and dealing with life. It takes seriously the human condition, being realistic to a fault, recognizes the limits of human nature, and deals dynamically and actively with the situation at hand. It uses rational thought and (depending on the client) faith-based tests to find answers to life's questions (Hoffman, 2004). While there are many theories of how to use existential theory among therapists, the focus is on trying to understand human existence. This generally brings theorists to the issues of freedom and responsibility, death, relationship, and meaning. But existential therapy is more an experiential approach than cognitive or intellectual, as it deals with the emotions and experience and it is most applicable to the kinds of clients who can apply their theoretical knowledge of existentialism to everyday life. (Cox, 2004)

Albert Ellis developed what he called the "DIE" model of interpretation of data.

Data, Interpretation and Emotional Response were determined by Ellis to be the keys to acting responsibly about causal effects. Ellis said that Data refers to any person, circumstance or event that is an occasion for a positive or negative emotion. Interpretation refers to our thoughts or believes about the data, and Emotional Response refers to the emotions resulting from one's interpretation of the data.

Ellis determined that if one uses rational thought and logic, then appropriate emotions may derive from one's interpretation of the data. Interpretations based on irrational and illogical thinking result in inappropriate emotions (this is called distortion and dysfunctional beliefs).

Incorrect logic leads to incorrect conclusions and therefore incorrect emotions. If one knew all the facts about an event, and used logical, rational thinking, then correct emotions would result. However, emotions may precede observing all the data, or in interpreting the data found. If emotions are there before the data or interpretation, an irrational or distorted and dysfunctional outcome is the result. In other words, if one is upset, one tends to view data that is received as the reason for upset feelings, whether or not it may have any affect or relationship. But if the data is there and has been reacted to inappropriately, then one has to go back and reexamine the information and perhaps its interpretation in order to disassociate the event from one's feelings

Ellis believed that one must look at the data objectively to see if it was directed towards one, or was totally unrelated. Critical examination of one's interpretation of data (self-talk, thoughts or beliefs) that supposedly has caused certain feelings (affect) may help one understand the dynamics of one's own response. Whereas it is hard to control other people and other events, one may certainly control one's own responses, since one produces one's own thoughts. It is up to each individual person to determine how he or she should respond to different situations. If one has had a distorted or dysfunctional response, one can critically examine and alter the interpretation and inappropriate behavior. Then one can logically dispute the interpretations and replace the cognitions (or thoughts about the event) with rational and functional reactions.

Glasser, a proponent of Choice (Reality) Theory, maintains that the client is internally motivated (to try and fulfill 'wants' and 'needs') and that behavior is 'total' and made up of four interconnecting components of acting, thinking, feelings and the physiology, each one accompanying the other three components. Acting and thinking are predominately voluntary; feelings and physiology are effectively changed through changing how the client acts and thinks. Additionally, Glasser states that "all of our significant conscious behavior," - that is, all behaviors that have anything directly to do with satisfying basic needs, - "are chosen" (Glasser, 1998) and that the choices that we make are perceived by us to be the best available choices at that time; even though we may later regret such choices and/or other people might perceive them to be ineffective, negative or antisocial etc. (Glasser, 2001)

The client retains responsibility for the behavioral choices he or she made and this is something that is emphasized strongly in teaching and practicing these ideas. Irrespective of the past, more effective choices can be made today and in the future. This truth is freeing. Choice (Reality) Theory is offered to replace what Glasser refers to as external control psychology, the present psychology of most of the world around us. This forcing, punishing psychology is destructive to any kind of relationship (be it between individuals, groups or even nations) and counterproductive to the quality and well being of virtually any kind of organization or enterprise. (Glasser, 2001)

Most of the modalities that have been examined herein and in past research have, as part of their theories, an examination of client goals.

Egan's model aids the counselor, as he or she helps the client focus in on short-term goals. Since the Egan model bases many of its tools on the empowerment of the individual, planning goes on throughout the process of working with others. (1998-301) Preliminary plans emerge out of discussions - words of what has to be done to make something that the client wants to occur come about. Plans to make a phone call, to obtain some kind of information, to talk to a friend about it; these are examples of preliminary planning. To help clients develop a response to a situation may not involve a full month of planning and keeping up with what has and will happen in order to reach a goal. Planning becomes part of a discussion.

Egan believes, there comes a time when one must sit down and map out future actions. Such times of organization - and what comes from them - are significant. Organizing future time helps clients that lack discipline from becoming overwhelmed by the future, provides for them means by which they may learn to prepare strategies; allow them to appreciate what is involved in planning and the obstacles they may meet as they move into the future. (1998-302).

For counselors using the Egan model, this may be a different sort of encounter with the client. The counselor may involve the client in brainstorming, making lists of different possible actions, and providing structures for forward thinking (perhaps involving them in different exercises or activities that illustrate this way to think). It may also may involve counselors helping the client to develop a new understanding of what this kind of thinking may mean in terms of actual formal planning.

Egan's model strategies for action for the client involve participating in the activities that need to take place if the client is to turn priorities into 'problem-solving accomplishments' (Egan 1998-29). In other words, working with the client to figure out what sort of planning and then action they need to be doing in order to get what they want. Egan suggests three aspects that interconnect:

Possible actions are: Working with the client to find ways to reach goals. The client asks him or herself: 'What do I need to do to get what I want?'

Impulsive and unplanned action. This is often unsuccessful. The client may claim to have attempted various ways to reach the goal with failure as their result. This is more a result of poor planning than proof that the task is impossible.

Getting clients to think up alternative ways to reach the goal is usually beneficial and inspiring to the client, resulting in more chances of success in reaching goals (Egan 1998-30).

For the previous work with the client to be of practical benefit, it needs to be connected to self-motivation, a problematic area for many people. The word motivation means to move in a direction of one's own choosing.

Abraham Maslow (1970) and B.F. Skinner (1974) researched motivation in depth. Maslow says people are motivated internally by personal needs yet to be fulfilled; Skinner said people are motivated by external rewards and punishments. Each one attempted to find the basic motivators, and research finds them both to be correct. Sometimes people push themselves, and at other times they are pulled. Therefore, motivation is described as "those forces acting on or within us that initiate behavior and give it direction." (O'Keefe, 7)

Feminist theory says that the root of the problem is not Freudian in nature, but is based on the roles that our age and culture has foisted upon one's gender unwillingly. The Feminist therapists coax the stories out of the clients, but emphasize asserting oneself in the present moment, empowering those who feel dominated and powerless in their daily and church lives.

In this way, Glasser has a similar theory. Dr. W. Glasser has been teaching Choice (or Reality) Theory since 1965. Believing that unsatisfactory or non-existent connections with people we need are the source of almost all human problems, he encourages the counselors to understand the concept of total behavior, which means to focus on what counselees can do directly -- "that is, to act and think. Spend less time on what they cannot do directly; that is, change their feelings and physiology. Feelings and physiology can be changed, but only if there is a change in the acting and thinking. Glasser also.advises counselors, as part of their developing a connection to the client, to avoid criticizing, blaming and/or complaining about things the client does, and this will help counselees to do the same. By doing this, they learn to avoid these extremely harmful external control behaviors that destroy relationships. At the very heart of Glasser's Choice Theory is the idea that the only person one can really control is one's self. (Glasser, 25)

Yet, while humans are influenced by external rewards and punishments, one moves only when external forces are internalized, when one "feels" like moving and "decides" to move.

Motivation is an inner state that initiates behavior and gives it direction. Since this inner state is an interaction between affect and cognition, motivation can be represented symbolically as a x C = B (Affect times Cognition equals Behavior.)

Egan says the key questions are: 'What should my campaign for constructive change look like?' 'What do I need to do First? Second?' (Egan 1998: 272)."

Egan (1998: 296-298) highlights some issues that arise when selecting strategies:

Wishful thinking. A client can easily choose a strategy without fully taking into account the risks, costs or obstacles to action. He or she may feel comfortable with a particular way of working or being, and firmly believe, despite evidence to the contrary, that this is the way to go.