Basic Principles of CBT The basic principle of CBT is that the way we think in specific situations affects how

we feel emotionally and physically, and alters our behaviour. Everyone will have their own, individual response to a particular event. The key to CBT is to identify the most important thoughts, feelings and behaviour that make up these reactions and decide whether these responses are rational and helpful. CBT helps people to understand their problems as well as offering techniques which enable people to learn to make changes in each of these areas, which leads to an improvement in emotional symptoms and empowers people to live fulfilling lives according to their own values and needs. Differing reactions to the same event: Imagine that you have cooked dinner for a friend, who is usually very reliable. An hour after she was due to arrive, there is still no sign and you have received no phone call. How would you react to this? Look at the following chart, which shows a variety of possible reactions to the same event:

How dare she do this to me! She is so Thoughts inconsiderate and rude!

She probably didn't want to come because she doesn't really like me. I'm such a loser.

What if she's had an accident? She could be seriously hurt.

I expect she's stuck in traffic. At least I have extra time to prepare dinner

Feelings

Angry

Depressed

Anxious

Relieved

Possible behaviou r

Tell her off or act Withdraw from chilly when she people and stop asking arrives them over

Phone local hospitals

Continue preparing dinner

No individual reaction is right or wrong. However, the way people react to events can often worsen their lives as a vicious cycle . For example, if someone feels depressed, they react by withdrawing from others, which only worsens their mood further. By identifying whether these reactions are helpful or unhelpful in achieving specific life goals, people can make choices about how to respond to different circumstances.

What evidence supports that thought? What evidence does not support that thought? Could there be any other explanations of the situation? If the worst thing were to happen, how bad would that be? What would you tell a friend if he or she were in the same situation?

Ce dori_i s_ ob_ine_i? - De unde ve_i _ti ca a_i ob_inut ceea ce v_ dori_i? - Cum va _ti altcineva c_ v-a_i ndeplinit obiectivul? - Ce se va ntmpla sau ce se va modifica dup_ ce ve_i ob_ine ceea ce v_ dori_i? - Ce v_ mpiedic_ s_ v_ realiza_i obiectivul? - Cnd dori_i s_ v_ ndeplini_i obiectivul? - Ce a_i putea pierde ob_inndu-l?

2. Multimodal Assessment And Treatment A. The BASIC I.D. Whereas many of the psychotherapeutic approaches used today are trimodal (addressing the familiar affect, cognition and behavior or "ABC"), the outcomes of several follow-up inquiries have pointed to the importance of therapeutic breadth if treatment gains were to be maintained. MMT addresses this problem by calling the clinician's attention to no less than seven discrete but interactive modalities. At base, we are all biological organisms (biochemical/neurophysiological entities), who behave (act and react), emote (experience affectiveresponses), sense (respond to tactile, olfactory, gustatory, visual and auditory stimuli), imagine (conjure up sights and sounds and other events in our mind's eye), think (hold beliefs, opinions, values and attitudes), and interact (enjoy, tolerate, or suffer various interpersonal relationships). Thus, MMT provides clinicians with a comprehensive assessment template. By separating sensations from emotions, distinguishing between images and cognitions, emphasizing both intraindividual and interpersonal behaviors, and underscoring the biological substrate, MMT is most far-reaching. In addition, as was mentioned above, by referring to these seven modalities as Behavior, Affect, Sensation, Imagery, Cognition, Interpersonal, and Drugs/Biology, the interactive modalities can be easily recalled by taking the first letter of each one to form the acronym "BASIC I.D." Using this assessment template will help to ensure that the clinician leaves no stone unturned. Students and colleagues frequently inquire as to whether particular modalities are more significant (and thus, should be more heavily weighted) than others. My typical response is that, whereas for thoroughness all seven modalities require careful attention, it is the biological and interpersonal modalities that are the most significant. Clearly, the biological modality wields a profound influence on all the other modalities: unpleasant sensory reactions can signal a host of medical illnesses; excessive emotional reactions (anxiety, depression and rage) may all have biological determinants; faulty thinking, and

images of gloom, doom and terror may derive entirely from chemical imbalances; and troublesome personal and interpersonal behaviors may stem from various somatic reactions ranging from toxins (e.g., drugs or alcohol) to intracranial lesions. It is, of course, essential when any doubts arise about the probable involvement of biological factors, to have them fully investigated by a qualified professional. Conversely, a person who has no problematic medical/physical problems and enjoys warm, meaningful and loving relationships is apt to find life personally and interpersonally fulfilling. Hence perhaps it is best to picture the biological modality serving as the base of a pyramid that contains each of the modalities, with the interpersonal modality at the apex. It must be emphasized, however, that the seven modalities are by no means static or linear, but instead exist in a state of reciprocal transaction. How does a clinician assess each of these modalities? Typically, through the use of a range of questions. For example, to assess the client's behavior, the clinician may ask: "What is this individual doing that is getting in the way of his or her happiness or personal fulfillment (self-defeating actions, maladaptive behaviors)?" Or perhaps, "What does the client need to increase and decrease?" Or even, "What should he/she stop doing and start doing?" To assess the client's affect the clinician may ask: "What emotions (affective reactions) are predominant?" Or, "Are we dealing with anger, anxiety, depression, or combinations thereof, and if so, to what extent (e.g., irritation versus rage; sadness versus profound melancholy)?" The clinician may ask, "What appears to generate these negative affects certain cognitions, images, interpersonal conflicts?" And, "How does the person respond (behave) when feeling a certain way?" Remember, however, that in addition to assessing each modality separately, it is also important to look for interactive processes that occur between and among the modalities (i.e., the impact that various behaviors have on the client's affect and vice versa). To assess the client's sensations, the clinician may ask: "Are there any specific sensory complaints (e.g., tension, chronic pain, tremors)?" Also, "What positive sensations (e.g., visual, auditory, tactile, olfactory and gustatory delights) does the person report?" Or, staying with the notion that one must also assess interactions among modalities, the clinician may ask, "What feelings, thoughts and behaviors are connected to these negative sensations?" It should be noted that assessment of this modality should also include the individual as a sensual and sexual being and, when called for, treatment interventions should be aimed at the enhancement or cultivation of erotic pleasure. To assess the client's imagery, the clinician may ask: "What fantasies and images are predominant?" "What is this client's self-image?" The clinician may also assess for specific success or failure images that the client holds, and will certainly want to ask whether the client experiences any negative or intrusive images (e.g., flashbacks to unhappy or traumatic experiences). Of course, as with the other modalities, the clinician will also want to assess how the client's images are connected to ongoing cognitions, behaviors, affective reactions, etc.

To assess the client's cognitions, the clinician may ask: "Can we determine the client's main attitudes, values, beliefs and opinions?" And, "Are there any definite dysfunctional beliefs or irrational ideas?" Or perhaps the clinician will assess the client's predominant "should statements" or try to detect any problematic automatic thoughts that undermine the client's functioning. To assess the client's interpersonal functioning, the clinician may ask: "Who are the significant others in this client's life?" Or, "What does this client want, desire, expect and receive from others, and what does he or she, in turn, give to and do for them? The clinician may also ask, "What relationships give this particular client pleasures and pains?" Finally, to assess the client's biological dimension, the clinician may ask: "Is this client biologically healthy and health conscious?" "Does he or she have any medical complaints or concerns?" And, "What relevant details pertain to diet, weight, sleep, exercise, and alcohol and drug use?" While a client presenting for treatment may use one of the seven modalities as his or her entry point (e.g., behavior: "It's my compulsive habits that are getting to me" or interpersonal: "My wife and are not getting along"), it is more typical for people to enter into treatment with problems in two or more of the modalities (e.g., "I have all sorts of aches and pains that my doctor tells me are due to tension, I worry too much, and I feel frustrated a lot of the time. I am also very angry with my father"). Initially then, it is usually advisable to engage the client by focusing on the presenting issues, modalities, and/or areas of concern that he or she presents. To deflect the emphasis too soon onto other matters that may seem more important is only inclined to make the patient feel invalidated. Once rapport has been established, however, it is usually easy to shift to more significant problems. It should be noted, however, that before fleshing out the details, any competent clinician would likely begin by addressing and investigating the presenting issues (e.g., "Please tell me more about the aches and pains you are experiencing." "Do you feel tense in any specific areas of your body?" "You mentioned worries and feelings of frustration. Can you please elaborate on them for me?" "What are some of the specific clash points between you and your father?"). The multimodal therapist will carefully note the specific modalities across the BASIC I.D. that are being discussed, and which ones are omitted or glossed over. The latter (i.e., the areas that are overlooked or neglected) can then be addressed, and often yield important clinical information. Thus, by thinking in BASIC I.D. terms, a clinician or counselor is apt to leave fewer important avenues unexplored. B. Second Order BASIC I.D. Whereas the initial BASIC I.D. is used to translate vague, general, or diffuse problems (e.g., I feel depressed or anxious) into specific, discrete, and interactive difficulties, which can then be addressed with various techniques (preferably those with empirical backing), Second Order BASIC I.D. assessments are typically saved for when therapy falters. Every clinician, regardless of his or her level of experience, reaches treatment

impasses. When this occurs, a more detailed inquiry into the associated behaviors, affective responses, sensory reactions, images, cognitions, interpersonal factors, and possible biological considerations may help to shed some light on the situation. For example, an unassertive person who is not responding to the usual social skills and assertiveness training methods, may be asked to spell out the specific consequences that an assertive way of living might have on his or her behaviors, affective reactions, sensory responses, imagery, and cognitive processes. Of course, interpersonal repercussions would also be examined and, if relevant, biological factors would be determined (e.g., "If I start expressing my feelings I may become less anxious and require fewer tranquilizers"). Quite often, this procedure can bring to light reasons behind such factors as noncompliance and poor progress. A case in point was a man who was not responding to role-playing and other assertiveness training procedures. Upon traversing a Second Order BASIC I.D. assessment, he revealed a central cognitive schemata to the effect that he was not entitled to be confident, positive, and in better control of his life, because this would only show up his profoundly reticent and inadequate father. Consequently, the treatment focus shifted to a thorough examination of his entitlements. C. Bridging Bridging (a strategy that is probably employed by most effective therapists) can readily be taught to novices via the BASIC I.D. foundation. The technique is best described through the use of an example. Let's say a therapist is interested in assessing a client's emotional response(s) to an event. The therapist might ask, "How did you feel when your father yelled at you in front of your friends?" Now suppose that instead of discussing his feelings, the client responded with a defensive and irrelevant intellectualization (e.g., "My dad had strange priorities and even as a kid I used to question his judgment"). If additional probes into this client's feelings only yield similar abstractions, it would likely be counterproductive to confront the client and point out that he is evading the question and that he seems reluctant to face his true feelings. Instead, in situations of this kind, bridging is usually more effective. First, the therapist would deliberately attune to the client's preferred modality (which in this case is the cognitive domain). Thus, the therapist would begin the bridging technique by exploring the client's cognitive content. The therapist might say, "So you see it as a consequence involving judgments and priorities. Please tell me more." After a five to ten minute discourse, the therapist would then endeavor to branch off into other directions that seem more productive. For example, the therapist may say, "Tell me, while we have been discussing these matters, have you noticed any sensations anywhere in your body?" This sudden switch from the cognitive modality to the sensory modality may then begin to elicit more pertinent information (given the assumption that in this instance, discussing sensory accounts would likely be less threatening to the client than discussing affective material).

The client may respond to this question by referring to some sensations of tension or bodily discomfort - for instance, "My neck feels very tense" -- at which point the therapist may ask him to focus on the specific tension. "Will you please close your eyes, and focus on that neck tension." After a brief pause, the therapist might say, "Now relax deeply for a few moments, breathe easily and gently, in and out, in and out, just letting yourself feel calm and peaceful." From here, the feelings of tension, their associated images and cognitions may then be examined. The therapist may then venture to bridge into the affective domain. The therapist might say, "Beneath the sensations, can you find any strong feelings or emotions? Perhaps they are there lurking in the background?" At this juncture it would not be unusual for the client to give voice to his feelings. The client might say, "I feel angry, and a little sad." Thus, by starting where the client is and then bridging into a different modality, most clients then seem to be willing to traverse the more emotionally charged areas they may have originally been avoiding. D. Tracking Tracking is a strategy that may be employed when clients are puzzled by affective reactions. For example, a client may say, "I don't know why I feel this way" or "I don't know where these feelings are coming from." The first step in tracking involves asking the client to recount the unpleasant event or incident. In true multimodal form, the client is then asked to consider what behaviors, affective responses, images, sensations, and cognitions come to mind. As was the case with bridging, this technique is best described through the use of an example. Let's say a therapist is working with a client who reported having panic attacks "for no apparent reason." Working together, the therapist and client were able to put together the following string of events. The client had initially become aware that her heart was beating faster than usual (sensation). This brought to mind a memory of a time in which she had passed out after drinking too much alcohol at a party (image). This memory still brought about a strong sense of shame (affect). As such, the client started believing that she would pass out again (cognition) and, as she dwelled on her sensations, this cognition was intensified and culminated in her panic attack. Thus, in this case, the client exhibited an S-I-A-C-S-C-A pattern (Sensation, Imagery, Affect, Cognition, Sensation, Cognition, Affect). Thereafter, the client was asked to note whether any subsequent anxiety or panic attacks followed a similar "firing order." Thereafter she confirmed that her two "trigger points" were usually in the Sensation and Imagery modalities. This alerted the therapist to focus on sensory training techniques (e.g., diaphragmatic breathing and deep muscle relaxation), followed immediately by imagery exercises (e.g., the use of coping imagery and the selection of mental pictures that evoked profound feelings of calm). While tracking can be useful in uncovering fairly reliable patterns behind negative affective reactions that clients find puzzling, clinicians should never assume that these patterns are universal and then use the same treatment techniques, in the same sequence, for all clients. For example, some clients dwell first on unpleasant sensations (palpitations, shortness of breath, tremors), followed by aversive images (pictures of disastrous events), to which they attach negative cognitions (ideas about catastrophic illness), leading to maladaptive behavior (withdrawal and avoidance). It is important to

underscore that this S-I-C-B firing order (Sensation, Imagery, Cognition, Behavior) may require a different treatment strategy from that employed with say a C-I-S-B sequence, an I-C-S-B, or some other firing order. Clinical findings suggest that it is often best to apply treatment techniques in accordance with a client's specific firing order. E. The Multimodal Life History Inventory After conducting the initial interview, many multimodal therapists elect to have their clients complete the Multimodal Life History Inventory (Lazarus & Lazarus, 1991, 1998). This 15-page questionnaire frequently facilitates treatment (when conscientiously filled in by clients as a homework assignment, usually after the initial session), by providing detailed background information and allowing for a more comprehensive problem identification sequence to be derived than would typically occur from the interview alone. The Multimodal Life History Inventory also generates a valuable perspective regarding a client's style and treatment expectations, and is typeset in such a manner that allows for an easy determination of specific excesses and deficits across a client's BASIC I.D. Of course, seriously disturbed (e.g., deluded, deeply depressed, highly agitated) clients would not be expected to comply, but most psychiatric outpatients who are reasonably literate will find the exercise useful for speeding up routine history taking and readily provide the therapist with a BASIC I.D. analysis. F. Structural Profile Inventory Yet another assessment tool for the multimodal therapist is the 35-item Structural Profile Inventory (SPI). The SPI evolved by generating a variety of questions that, on the basis of face validity, appeared to reflect essential components of the BASIC I.D. (Lazarus, 1997). The SPI yields a quantitative BASIC I.D. graph that depicts a person's degree of activity, emotionality, sensory awareness, imagery potential, cognitive propensities, interpersonal leanings, and biological considerations (Lazarus, 1997). The SPI may also be particularly useful in couples therapy, where differences in the specific ratings may indicate potential areas of friction. Discussion of these disparities with clients can result in constructive steps to understand and remedy them. A series of studies (e.g., Herman, 1993; Landes, 1988) have established the reliability and validity of the SPI. Of special interest is the fact that Herman (1991, 1997) has also shown that client-therapist similarity on the SPI is predictive of psychotherapy outcome. Multimodal therapists may also make use of several other specialized assessment instruments (e.g., The Expanded Structural Profile and The Revised Marital Satisfaction Questionnaire), which are described in detail elsewhere (e.g., Lazarus, 1997). It should be emphasized, however, that wherever applicable, multimodal therapists will also strive to administer additional well-known (and preferably, empirically supported) assessment measures such as the Beck Depression Inventory (Beck, 1988), and YBOCS (Goodman et al., 1989). Top of Page 3. Clinical Indications And Exlcusions

While MMT offers a comprehensive orientation that is extremely flexible and ardently strives to match the best and most effective methods with the appropriate treatments for each individual, there do exist several situations in which one may elect not to work multimodally. For example, as mentioned above, a clinician treating a client with serious psychopathology (e.g., active delusions, extreme depression, pervasive anxiety) would not likely have much luck getting the client to complete the Multimodal Life History Inventory. In addition, certain situations call for an immediate, highly focused crisis intervention sequence, in which the emphasis would be on methods that are more likely to be limited but intense. Similarly, there is often no need to delve into broader or deeper issues with clients whose problems call for immediate and obvious interventions. For example, a business executive who is uncomfortable flying may seek treatment because her job calls for frequent air travel. In this case, the entire treatment may entail no more than three desensitization sessions coupled with mental imagery and autohypnotic skills that she can use as needed. It is also not uncommon to encounter high functioning individuals whose problems call for a bimodal intervention (e.g., cognitive restructuring and social skills training), or who simply need little more than a good shoulder to cry on (metaphorically speaking), an active listener, or an authority figure who will affirm their own perceptions or judgment, or offer reassurance and good advice. Thus, in practicing MMT, one does not mindlessly apply the multimodal spectrum across the board, but instead, when indicated, the well-trained multimodal clinician has an imposing armamentarium of assessment and treatment strategies at his or her disposal. Recall that MMT is a clinical approach that rests on a social and cognitive learning theory, and is therefore not a unitary or closed system. Instead it uses technically eclectic and empirically supported procedures in an individualistic manner. Obviously, there is no one therapist who can be well versed in the entire gamut of methods and procedures that exist today. Therefore it should go without saying that if a problem or a specific client falls outside their sphere of expertise, the competent clinician will endeavor to effect a referral to an appropriate resource. Top of Page 4. Empirical Support For MMT A common question is whether there is evidence that MMT (or any other broad spectrum approach) is superior to more narrow or targeted treatments. Historically, the data on this subject have been mixed. For example, in the 1970s and 1980s, researchers found that for some disorders, specialized or highly focused interventions were indeed superior to broad-spectrum (or multimodal-like) approaches. One example would be the finding that in weight-loss programs a specialized stimulus-control procedure was often superior to multidimensional treatments. Conversely, a strong argument was made for a broad-

spectrum approach in the treatment of alcoholism. Here, studies found that those treated only by aversion therapy were more likely to relapse than their counterparts who had received aversion therapy plus relaxation training. It is, of course, far easier to study the impact of a specific technique than to measure the effectiveness of an entire clinical armamentarium such as MMT. Nevertheless, colleagues in Scotland and Holland have attempted to do so. For example, in a carefully controlled outcome study conducted by Dr. Tom Williams, MMT was compared with less integrative approaches in helping children with learning disabilities, with the results clearly supporting the use multimodal procedures (Williams, 1988). In addition, Dr. M.G.T. Kwee conducted a controlled outcome study of multimodal treatment on 84 hospitalized patients suffering from obsessive-compulsive disorders or phobias, 90% of who had received prior treatment without success, and 70% of who had suffered from their disorders for more than 4 years (Kwee, 1984). In this case, implementing MMT resulted in substantial recoveries and durable nine-month follow-ups. Aside from outcome measures, there also is research bearing out certain multimodal tenets and procedures. For example, as mentioned above, multimodal clinicians often elect to use the Structural Profile Inventory (SPI). Factor analytic studies gave rise to several versions of the SPI until one with good factorial stability was obtained. For example, the reliability and validity of this instrument was investigated in a series of studies by Dr. S. Herman (e.g., Herman 1991, 1993, 1997). One of the most important findings was that when clients and therapists have wide differences on the SPI, therapeutic outcomes tend to be adversely affected (Herman, 1991). Top of Page Summary Multimodal therapy draws on the same principles of experimental and social psychology, as do other cognitive-behavioral therapies. It emphasizes that for therapy to be comprehensive and thorough it must encompass seven discrete but interactive modalities - behavior, affect, sensation, imagery, cognition, interpersonal relationships, and drugs/biological considerations. The first letters of the foregoing dimensions yield the convenient acronym BASIC I.D. This results in broad-based assessment and treatment foci. It may be stated that a specific MMT theory is that the reciprocal reactions among and between the seven modalities comprise the essence of human temperament and personality, and point the way to rapid and durable therapeutic tactics and strategies. Whenever feasible, multimodal therapy practitioners use empirically supported treatment methods. The therapeutic relationship is pivotal. Rapport and compatibility between client and therapist is the soil that enables the techniques to take root. Multimodal therapy is technically but not theoretically eclectic. It makes effective use of methods from diverse sources without relinquishing its social learning and cognitive theoretical

underpinnings. Fitting the requisite treatment to the specific client (and not vice versa) is an essential goal.