Multimodal therapy and eclectic psychotherapy

1. Introduction

Version followed: Arnold A. Lazarus's multimodal therapy (MMT) as he describes it in his own published case study (Lazarus 2005, "The case of 'Ben'", Pragmatic Case Studies in Psychotherapy, full text), in his Erickson Foundation workshop descriptions, and in the publisher's contents list for The Practice of Multimodal Therapy (1989), supplemented by the GetSelfHelp MMT pages (which Lazarus endorsed in 2011) and Clifford N. Lazarus's accounts (2015, 2019). Sol L. Garfield's approach follows Psychotherapy: An Eclectic-Integrative Approach (2nd ed., 1995) from its publisher description and table of contents. Sourced: the terms "Modality Profile" and "Structural Profile" (Lazarus workshop objectives); bridging and tracking as methods Lazarus presented as unique to MMT; the Initial Review, BASIC I.D. interactions, Deserted Island Fantasy, client–therapist compatibility and technique-selection chapters of the 1989 book; the MLHI's use as homework and as a progress check; the techniques Lazarus himself used per modality in a published case; Garfield's 1995 chapter structure, including a chapter on common and specific factors. Still unverified: the full texts of Lazarus's books (1989, 1997) and his handbook chapters; the Structural Profile items and rating format; the operational steps of bridging, tracking and the second-order BASIC I.D.; the Deserted Island Fantasy procedure; a standard session count; Garfield's own list of common factors and his phase-by-phase procedures. These are marked [uncertain] or [synthesis].

What it is. These two approaches are not single therapies with their own set of techniques. They are frameworks for choosing techniques from many schools and combining them. Lazarus called his position technical eclecticism, defined in a later account as "using empirically supported methods without adherence to the method's theoretical foundation" [source: C. N. Lazarus 2015, SAGE entry "Lazarus, Arnold"]. Lazarus himself described MMT as a cognitive-behavioural framework that draws on other traditions through technical eclecticism [source: Lazarus 2005, PCSP]. Lazarus held that techniques from any school can be used without reconciling their theories, and that theoretical eclecticism is not yet possible [source: Kertész 2005, summarising Lazarus]. MMT rests on social and cognitive learning theory [source: C. N. Lazarus 2019; Bhatnagar teaching notes]. Lazarus worked with Joseph Wolpe in early behaviour therapy, then added cognitive factors after finding purely behavioural methods too limiting, and then developed MMT [source: C. N. Lazarus 2015, SAGE entries]. Garfield's eclectic approach states no single theoretical orientation. It is also not a loose mix of techniques. It links ideas shared across therapy systems and adds methods shown to work for specific disorders [source: Garfield 1995, publisher description].

How change happens (MMT). Problems are multifaceted. They show up across seven interacting modalities, summed up in the acronym BASIC I.D.:

• Behaviour
• Affect
• Sensation
• Imagery
• Cognition
• Interpersonal relationships
• Drugs/biology (medication, substances, diet, exercise, sleep and general health)

Lazarus describes the seven as "discrete but interactive dimensions or modalities" [source: Lazarus 2005, PCSP]. The modalities influence one another in both directions. Change is more lasting when the therapist assesses each modality and treats the significant problems in each, rather than working on one channel only. Lazarus's phrase for this is "leaving no stone unturned", going beyond affect, behaviour and cognition to imagery, sensation, relationships and biology [source: Lazarus EP90 workshop description; Lazarus 2005; GetSelfHelp MMT; C. N. Lazarus 2019]. Lazarus described MMT as "brief but comprehensive" psychotherapy (1997 book title) [source: GetSelfHelp MMT; Kobe library record].

How change happens (Garfield). Garfield builds therapy on factors shared across therapy systems and adds methods shown to work for specific disorders. Client variables, therapist variables and "therapeutic variables" each get their own chapter, and chapter 5 is titled "Common and Specific Factors in Psychotherapy" [source: Garfield 1995, Wiley description and table of contents]. Garfield's own list of common factors is not drawn on. Grencavage & Norcross (1990) cite his 1980 book as a common-factors source but do not reproduce his list. Any named factors below (relationship, hope, a plausible rationale) are therefore [uncertain].

2. Framework

Multimodal therapy

Lazarus's 1989 book moves "from the initial interview through relapse-prevention follow-up" (publisher's description, paraphrased). Its chapters run: basic rationale and method; basic concepts; the Initial Review; the multimodal assessment–therapy connection; determining BASIC I.D. interactions; the Deserted Island Fantasy technique; relationship factors and client–therapist compatibility; the selection of techniques; then marriage therapy, sex therapy, and work with children, groups and the severely disturbed [source: JHU Press page for Lazarus 1989]. The stages below follow that order. The goals within each stage come from the sources where tagged; otherwise they are [synthesis].

1. Initial review (Lazarus's chapter title) [source: JHU Press TOC].
   • Goal: learn the presenting problems, what the client wants from therapy and how they want the therapist to work, for example as a sounding board or as an active trainer [source: GetSelfHelp MMT; Lazarus 2005].
   • Explain the approach. In the Ben case, Lazarus said history mattered only up to a point, and framed therapy as education with homework [source: Lazarus 2005].
   • Assess client–therapist compatibility; Lazarus gives this its own chapter [source: JHU Press TOC].
   • With written consent, contact earlier therapists [source: Lazarus 2005].
   • Lazarus warned against wasting time [source: GetSelfHelp MMT].
2. Comprehensive assessment.
   • The client completes the Multimodal Life History Inventory (MLHI) at home after the first session [source: Lazarus 2005; GetSelfHelp MMT].
   • The Structural Profile shows which modalities the client relies on [source: Lazarus EP90 workshop; Bhatnagar].
   • The therapist turns vague complaints into specific, separate, interacting problems placed across all seven modalities, and works out how the modalities interact ("Determining BASIC I.D. Interactions" is a chapter title) [source: JHU Press TOC; Bhatnagar].
   • Move on once every modality has been reviewed [synthesis].
3. Treatment planning: the Modality Profile.
   • Draw up a Modality Profile (problems and proposed treatments per modality) [source: Lazarus EP90 workshop objective].
   • Clients with the same diagnosis can get very different plans [source: GetSelfHelp MMT; C. N. Lazarus 2019].
   • Client motivation and resilience set the pace, the order of problems and the amount of homework [source: Lazarus 2005].
4. Intervention and monitoring.
   • Select techniques (empirically supported first) [source: Lazarus 2005; JHU Press TOC].
   • Use bridging and tracking to sequence the work [source: Lazarus EP05 workshop description].
   • Re-administer measures and the MLHI to check progress. Lazarus used the Beck Depression Inventory and an MLHI review at about 15 months in the Ben case [source: Lazarus 2005].
   • Be ready to reorder priorities when crises arise [source: Lazarus 2005].
   • If therapy stalls, assess the stuck problem again with a second-order BASIC I.D. [source: Bhatnagar; uncertain in Lazarus's own wording].
5. Ending and relapse-prevention follow-up.
   • The 1989 book covers relapse-prevention follow-up [source: JHU Press description].
   • In the Ben case, sessions were spaced from weekly to every 2–4 weeks, then held as needed, with follow-up contact for years [source: Lazarus 2005].
   • Reasonable criteria for ending [synthesis]: the planned problems in each modality are resolved or reduced, and the client can use the techniques on their own.

Session count and format. Lazarus called MMT brief but comprehensive, but no standard number of sessions was found [uncertain]. In his own published case, he first expected "a 5 or 6-session trajectory". Crises extended it to about two years of contact, weekly at first and then every 2–4 weeks, with joint couple and family sessions as needed [source: Lazarus 2005]. Read this as: plan briefly, extend when new problems emerge. Format: individual therapy mainly, plus marriage, sex therapy, children, groups and severely disturbed clients (chapters of the 1989 book) [source: JHU Press TOC; Bhatnagar]. The MLHI is completed between sessions [source: Lazarus 2005; GetSelfHelp MMT].

Garfield's eclectic psychotherapy

The 1995 edition has chapters on the client, the therapist and therapeutic variables, then "The Beginning Phase of Psychotherapy", "The Middle and Later Phases of Psychotherapy", "Terminating Psychotherapy" and "Brief and Long-Term Psychotherapy" [source: Garfield 1995, Wiley TOC]. The phase names are verified. The goals and criteria below were not seen in the text [synthesis/uncertain]:

• Beginning phase. Build the relationship and the client's expectation that therapy can help. Assess the problem and agree on goals. Give the client an understandable explanation of the problem and of how therapy will work. Move on once there is a working alliance and agreed goals.
• Middle and later phases. Apply the common factors, plus specific procedures that have evidence for the presenting problem. Monitor progress.
• Terminating phase. End as planned. Consolidate gains and prepare the client for setbacks.

The 1995 book compares brief and long-term therapy in its own chapter and reviews research on short-term therapy [source: Garfield 1995, Wiley description and TOC]. Garfield's 1989 and 1998 books are titled The Practice of Brief Psychotherapy. His recommended number of sessions was not found [uncertain].

3. Guiding principles

Principles marked [source] come from the cited pages. The rest are [synthesis].

Multimodal therapy

• Comprehensiveness ("leave no stone unturned"). Check all seven BASIC I.D. modalities for every client. Ask about sleep, health, imagery and relationships even when the complaint sounds purely emotional [source: Lazarus EP90 workshop; Lazarus 2005; C. N. Lazarus 2019].
• Specificity. Turn a diffuse complaint such as "I'm depressed" into concrete, separate problems, each placed in a modality [source: Bhatnagar; Lazarus 2005 modality questions].
• Modalities interact. The modalities are separate but interact. A change in one, such as sleep, can shift others, such as mood and thinking. Plan with these chains in mind [source: Lazarus 2005; C. N. Lazarus 2019].
• Excesses and deficits. Treat both: actions to decrease or stop, and actions to increase or start [source: Lazarus 2005 behaviour questions; C. N. Lazarus 2019].
• Fit the treatment to the patient. Neither the diagnosis nor the therapist's habits dictate the plan. The client's profile across the modalities does [source: JHU Press description; C. N. Lazarus 2019; GetSelfHelp MMT].
• Technical eclecticism, not theoretical integration. Borrow techniques from any school, but do not blend theories that may contradict each other. Explain techniques within a cognitive-behavioural, social-learning account [source: Lazarus 2005; Kertész 2005; C. N. Lazarus 2015].
• Empirically supported methods first. "The use of empirically supported methods is a first choice" [source: Lazarus 2005].
• Client–therapist compatibility; fit your style. Ask early whether the client wants a reflective listener or an active trainer, and adjust. Lazarus was willing to be educational and directive and to take a stand, and he criticised therapists who never answer questions directly [source: Lazarus 2005; GetSelfHelp MMT; JHU Press TOC].
• Brief but comprehensive; do not waste time. Every session should target a listed problem. Lazarus limited how much time went on the past [source: GetSelfHelp MMT; Lazarus 2005].
• Pace by motivation and resilience. These decide how fast to go, which problem comes first and how much homework to set [source: Lazarus 2005].
• Be ready for the unexpected. "A clinician must always be ready to address unexpected events." Re-prioritise when crises arise [source: Lazarus 2005].
• Biology at the base, interpersonal at the top. The cited summary says Lazarus saw the biological and interpersonal modalities as the most significant [source: Bhatnagar]. Clear up medical and biological factors early, for example by referral for a medication assessment [source: Lazarus 2005 case].
• Start where the client is (bridging) and follow their sequence (tracking). Lazarus presented both as methods unique to MMT [source: Lazarus EP05 workshop description; GetSelfHelp MMT; Bhatnagar].
• Re-assess when stuck. When progress stalls, assess the stuck problem in more detail before blaming the client [source: Bhatnagar].

Garfield's eclectic psychotherapy

• No school allegiance, but not haphazard. Each choice should follow from the client's problem and from evidence, not from habit or a fixed theory [source: Garfield 1995 description].
• Common factors first, specific factors added. Build the relationship, hope and a credible rationale, then add specific techniques. Garfield devotes chapter 5 to common and specific factors [source: Garfield 1995 TOC]. The specific factors named here are [uncertain].
• Attend to the client and to yourself. Client characteristics and therapist characteristics both shape outcome, and each has its own chapter [source: Garfield 1995 TOC]. Practical meaning [synthesis]: assess expectations, motivation and fit, and monitor your own contribution.
• Use disorder-specific methods where they exist. For example, use exposure-based methods for anxiety disorders [source: Garfield 1995 description; the example is synthesis].
• Keep it brief when possible. Plan for short-term therapy with a defined ending. Garfield compares brief and long-term therapy [source: Garfield 1995 TOC; titles of Garfield 1989/1998; synthesis for the detail].
• Stay research-informed and evaluate outcomes. Two chapters cover research and evaluating effectiveness [source: Garfield 1995 TOC]. Revise your methods as research changes, and measure your own outcomes [synthesis for the practice rule].

4. Intervention inventory

Neither approach owns a set of therapy techniques. MMT's own contribution is a set of procedures for assessing, planning and sequencing treatment (items A1 to A8a). Lazarus's 1989 book has a "Glossary of Principal Techniques" (37 techniques, Appendix 2) [source: JHU Press page]. That glossary is not drawn on. A9 therefore lists the techniques Lazarus himself used, by modality, in his published Ben case [source: Lazarus 2005], plus a wider menu marked [synthesis] that is not attributed to Lazarus. Garfield's procedures (B1 to B5) follow the verified phase structure of his 1995 book, but their steps are [synthesis/uncertain]. All example wording is illustrative.

A1. Initial review: expectations, compatibility and preferred style

• Purpose / when: First session(s). "The Initial Review" is a chapter of Lazarus 1989; client–therapist compatibility is another [source: JHU Press TOC]. Learn what the client wants, how they want you to behave, and whether you are a good fit [source: GetSelfHelp MMT; Lazarus 2005].
• Steps:
  • Ask for the main complaints and what the client hopes will change.
  • Ask whether they want you mainly as a listener or as an active trainer who gives advice and homework. Ben chose "an active trainer" [source: Lazarus 2005; GetSelfHelp MMT].
  • Explain the approach. Lazarus told Ben that history matters only so far, comparing too much focus on it to driving while looking only in the rear-view mirror. He then framed therapy as education: skills practice, homework, and "doing things differently and doing different things" [source: Lazarus 2005].
  • With the client's written permission, contact any previous therapist [source: Lazarus 2005].
  • Note complaints by modality as they come up, for example "can't sleep" under D and "keep picturing failing" under I [synthesis].
  • Give the MLHI to complete at home (A3) [source: Lazarus 2005].
• Example language (illustrative): "What would you most like to be different by the end of our work?" "Some people want me mostly to listen; others want an active coach who gives tasks between sessions. Which would suit you?"
• Watch for: A poor fit between your style and what the client wants. Adjust, or consider referral if the fit cannot be made [synthesis; Lazarus's compatibility chapter not drawn on]. It is working if the client agrees with your summary of what they want and of the agreed way of working, and accepts the rationale. Ben's response was "Sounds good to me" [source: Lazarus 2005].

A2. BASIC I.D. problem identification (first-order assessment)

• Purpose / when: Throughout assessment. Turn vague complaints into specific, separate problems that interact, covering all seven modalities [source: Lazarus 2005; Bhatnagar; C. N. Lazarus 2019].
• Steps: Take each modality in turn and ask the guiding questions Lazarus lists (paraphrased) [source: Lazarus 2005]:
  • Behaviour: which self-defeating actions should increase, decrease, stop or start?
  • Affect: which emotions dominate, how intense are they, and what sets them off?
  • Sensation: what physical complaints, and what pleasant sensations?
  • Imagery: what images, self-image and intrusive memories?
  • Cognition: which beliefs, "shoulds" and automatic thoughts?
  • Interpersonal: who are the significant others, and what goes on between them and the client?
  • Drugs/biology: health, sleep, exercise, diet, medication and substance use.
  • Write each problem on its own line under its modality.
  • Ask how the problems influence one another ("Determining BASIC I.D. Interactions" is a chapter of Lazarus 1989; its procedure is not drawn on), for example "After you sleep badly, what happens to your thoughts and mood?" [synthesis wording].
• Example language (illustrative): "When you say you're 'stressed', what do you actually do differently? What do you feel in your body? Do any pictures come into your mind? What do you tell yourself?"
• Watch for:
  • Modalities the client skips or dismisses. Compare with the Structural Profile.
  • Concealed problems. Lazarus judged that Ben was at first "faking healthy" about depression [source: Lazarus 2005]. Re-ask and re-measure later.
  • Always ask about the D modality and arrange medical or psychiatric review where indicated [source: Lazarus 2005 referral; synthesis for the general rule].

A3. Multimodal Life History Inventory (MLHI)

• Purpose / when: After the first session, as homework. A detailed questionnaire, with qualitative and quantitative parts, covering history and current problems across the seven modalities. It saves session time on history-taking and points to troublesome areas [source: Lazarus 2005; GetSelfHelp MMT]. Later it can be re-used as a progress check [source: Lazarus 2005]. Versions: "Multimodal Life History Questionnaire" (Appendix 1 of Lazarus 1989) [source: JHU Press TOC]; later the MLHI by Lazarus & Lazarus (1991; 3rd ed. 1998). It is a copyrighted instrument; use a purchased copy. Its items are not reproduced here.
• Steps:
  • Explain its purpose: it saves session time and gives a full picture.
  • Ask the client to complete it at home and bring it back [source: Lazarus 2005].
  • Read it before the next session, note problems by modality, and check any risk and medical items at once [synthesis].
  • Discuss omissions and anything striking [synthesis].
  • Progress review: months into therapy, ask the client to go back through the inventory and mark what has been dealt with, what still needs work, and any new problems. Lazarus did this at about 15 months with Ben [source: Lazarus 2005].
• Example language (illustrative): "This questionnaire is long, but it means we won't spend sessions on routine history. Skip anything you'd rather discuss in person."
• Watch for: Literacy, language, depression-related fatigue or overwhelm. Offer to complete it together in session, or in parts [synthesis]. It is working if the returned inventory gives concrete material for each modality.

A4. Structural Profile (Structural Profile Inventory; Expanded Structural Profile)

• Purpose / when: During assessment. Shows how much the client relies on each modality, which helps with bridging, tracking and choosing techniques. Lazarus taught clinicians "to draw up Modality Profiles and Structural Profiles" for assessment and treatment planning [source: Lazarus EP90 workshop objective; Bhatnagar]. A "Structural Profile Inventory" is Appendix 4 of Lazarus 1989 [source: JHU Press TOC]; GetSelfHelp links an Expanded Structural Profile hosted with Lazarus's permission. The items and rating format are [uncertain]. Use the published form; do not improvise its items.
• Steps:
  • Give the Structural Profile Inventory, or ask the client to rate themselves on each modality, for example how much of a "doer", "feeler", "imaginer" or "thinker" they are [synthesis wording].
  • Sketch the profile, for example as one bar per modality.
  • Identify the dominant modalities (where to start) and the neglected ones.
  • A "desired profile" step, in which the client rates how they would like to be, is [uncertain]. A Spanish-language version of the multimodal profile uses "current state" and "desired state" columns [source: Kertész 2005], but that is a problem table, not Lazarus's Structural Profile.
  • In couples work, partners can compare their profiles to understand mismatches [synthesis].
• Example language (illustrative): "You rate yourself very high on thinking things through and low on noticing body sensations. That gives us a starting point, and also a gap to work on."
• Watch for: A profile is a self-description, not a test score. It is working if the client recognises themselves in it and it shapes how you introduce techniques.

A5. Multimodal treatment plan (problems and interventions by modality)

• Purpose / when: After assessment. Lazarus's term is Modality Profile: a chart listing, for each modality, the specific problems and the proposed treatment for each [source: Lazarus EP90 workshop objective (term verified); GetSelfHelp MMT shows an example plan for depression as an image only]. Version note: Kertész (2005), working in Spanish, uses a table with columns for current state, desired state, techniques and results, quantified where possible [source: Kertész 2005]. Lazarus's exact column layout is [uncertain].
• Steps:
  • Make a table: modality, problem, proposed intervention (and, if you use Kertész's version, desired state and result).
  • Fill one row per problem, drawing on A2 to A4.
  • For each problem, choose an empirically supported technique first [source: Lazarus 2005; C. N. Lazarus 2019].
  • Review the plan with the client, invite changes and agree priorities.
  • Decide order and pace by the client's motivation and resilience [source: Lazarus 2005]. Start in the modality most likely to benefit the client, or their dominant one [source: GetSelfHelp MMT].
  • Revisit the plan when circumstances change. Ben's plan was put on hold by session three when a relationship crisis took priority [source: Lazarus 2005].
• Example language (illustrative): "Here's what we've found under each heading, and what I suggest for each. Which feels most urgent to you? Is anything missing?"
• Watch for:
  • Plans so long that they overwhelm. Prioritise three or four targets at a time [synthesis].
  • Interventions that clash with each other or with the client's values.
  • It is working if the client owns the plan and can say why each item is there.

A6. Bridging

• Purpose / when: Lazarus presented bridging and tracking as "methods unique to Multimodal Therapy" [source: Lazarus EP05 workshop description]. Use bridging when a client stays in one modality, for example talking only in ideas when you want to reach feelings, or when an early intervention misses. First connect in the client's preferred modality, then move toward other, more productive modalities [source: Bhatnagar; GetSelfHelp MMT].
• Steps (Lazarus's own operational description is not drawn on; these steps are [synthesis]):
  • Notice the client's current modality, for example cognitive, abstract talk.
  • Respond within that modality for a few exchanges, using its language.
  • Ask about a neighbouring modality, such as sensation or imagery, linked to what they are discussing.
  • Move gradually toward the target modality, such as affect.
  • If the client goes back, return to their modality and try another route later.
• Example language (illustrative): Stay with the client's explanation first: "So your reasoning is that the restructure makes your role redundant." Then bridge: "As you go through that, what do you notice in your body?" Then: "And if that tension had a feeling attached, what would it be?"
• Watch for: Pushing too fast feels to the client like being dismissed. It is working when the client starts to describe the target modality on their own.

A7. Tracking (firing order)

• Purpose / when: Tracking is the second of the two methods Lazarus called unique to MMT [source: Lazarus EP05 workshop description]. It identifies the order in which a client's modalities typically "fire" in a problem episode, so that interventions can follow that order [source: GetSelfHelp MMT; Bhatnagar]. It relates to the 1989 chapter "Determining BASIC I.D. Interactions" [source: JHU Press TOC; how the chapter treats it is uncertain].
• Steps (operational detail is [synthesis]):
  • Take a recent, specific episode, such as a panic attack or an outburst.
  • Ask step by step what came first, for example a bodily sensation, then an image, then a thought, then an emotion, then a behaviour.
  • Repeat with two or three more episodes to see whether the order is consistent.
  • Start the intervention at the first link in the chain, for example relaxation or breathing for a sensation-first chain, cognitive work for a cognition-first chain [synthesis examples].
  • Share the sequence with the client as a short formulation.
• Example language (illustrative): "Let's slow that moment right down. What was the very first thing you noticed? And then? And after that?"
• Watch for: The order can differ between clients with the same diagnosis, and between problems in the same client. It is working when an intervention aimed at the first link reduces the whole episode.

A8. Second-order BASIC I.D.

• Purpose / when: When therapy stalls on a problem, or a standard technique has not worked. You repeat the BASIC I.D. assessment on that one problem in finer detail [source: Bhatnagar].
• Steps (operational detail is [synthesis]):
  1. Name the stuck problem precisely, for example "still not attending social events".
  2. Go through all seven modalities for that problem alone: what the client does, feels, senses, pictures and thinks about it; who else is involved; and any biological factors, such as fatigue, medication effects or alcohol.
  3. Look for a modality the first assessment missed, for example a vivid humiliating image that drives avoidance.
  4. Pick a new intervention aimed at that modality.
  5. Review the result after one to two weeks.
• Example language (illustrative): "We've been stuck on this, so let's look at it under a microscope. When you think of going to the party, what picture comes into your mind? What do you feel in your body?"
• Watch for: Frame it as refining the plan, not as the client failing. It is working if a new target appears and movement resumes.

A8a. Deserted Island Fantasy technique [uncertain]

• Purpose / when: Lazarus gives this assessment technique a whole chapter of The Practice of Multimodal Therapy (1989, chapter 6), placed between the assessment chapters and the chapter on client–therapist compatibility [source: JHU Press TOC]. The chapter's purpose, timing and steps are [uncertain].
• Steps: Not given here. The procedure is [uncertain], and this guide does not reconstruct it. Read chapter 6 of Lazarus (1989) before using it.
• Example language: None. No wording has been verified.
• Watch for: Do not improvise a version and present it as Lazarus's method.

A9. Selecting techniques within each modality (technical eclecticism) [Lazarus case list sourced; wider menu synthesis]

• Purpose / when: At every treatment-planning step. Choose empirically supported techniques from any school, matched to the specific problem, without adopting their theories, and conceptualise them within CBT [source: Lazarus 2005; C. N. Lazarus 2019]. "The Selection of Techniques" is chapter 8 of Lazarus 1989, and Appendix 2 is a glossary of 37 principal techniques; neither is drawn on here [source: JHU Press page].
• Steps:
  • For each problem, ask which technique has the best evidence for this specific problem, and whether this client can and will do it.
  • Explain the technique in social-learning terms, as learning a new response [synthesis].
  • Rehearse it in session. Lazarus modelled assertive replies and had Ben "try them on for size" [source: Lazarus 2005].
  • Set homework, with the amount fitted to the client's motivation [source: Lazarus 2005].
  • Review it at the next session.
• Techniques Lazarus used in the Ben case, by modality [source: Lazarus 2005]:
  • Behaviour: role-play, assertiveness training, anger management, a gym programme; homework on doing things differently.
  • Affect: anger management; encouraging emotional risk-taking, such as expressing true feelings.
  • Sensation: relaxation training; regular massage.
  • Imagery: imagery of coping with adversity.
  • Cognition: cognitive restructuring of dichotomous thinking, "shoulds" and self-downing; pros-and-cons "balance sheets" for a decision.
  • Interpersonal: CBT couples sessions, joint family sessions, a community grief group, time with friends.
  • Drugs/biology: referral to a psychopharmacologist (prescribing left to the prescriber); exercise.
• Wider menu [synthesis, not attributed to Lazarus]:
  • Behaviour: behavioural activation, graded tasks, self-monitoring, stimulus control; exposure with response prevention only with consent, a clear rationale, a collaborative hierarchy and screening for contraindications.
  • Affect: naming and rating emotions; distress-tolerance skills.
  • Sensation: progressive muscle relaxation; slow breathing; sensate focus (sex therapy, after medical review); grounding through the senses.
  • Imagery: coping imagery and rehearsing feared situations in imagination; positive future imagery; rescripting distressing images, in trauma only after stabilisation.
  • Cognition: correcting misinformation; problem-solving training; bibliotherapy.
  • Interpersonal: communication-skills and social-skills training; contracting.
  • Drugs/biology: medical assessment; sleep-hygiene education; reducing substance use; general health routines (no specific dietary or exercise targets).
• Example language (illustrative): "For the arguments at home, I'd suggest practising a specific way of raising complaints. I'll show you one way to say it; then you try it on for size."
• Watch for:
  • Eclecticism without a rationale. Every technique must map to a listed problem.
  • Techniques outside your competence, such as trauma processing or hypnosis. Train or refer.

A10. Adapting for couples, families, groups and children

• Purpose / when: Lazarus's 1989 book has chapters on multimodal marriage therapy, multimodal sex therapy, and work with children, groups and the severely disturbed, plus a Marital Satisfaction Questionnaire (Appendix 3) [source: JHU Press TOC]. In the Ben case, Lazarus moved from individual CBT to couples counselling and joint family sessions when the problems became relational. He told the family he would not take sides, and he referred Ben to a grief group [source: Lazarus 2005]. Other procedures below are [synthesis].
• Steps:
  • Assess each person's BASIC I.D. and, where useful, their Structural Profile.
  • For couples, use the Marital Satisfaction Questionnaire (a purchased or published copy; items not reproduced) [source: JHU Press TOC; how it is used is not drawn on].
  • In joint sessions, state your neutrality at the outset [source: Lazarus 2005]. Use role-play and clarifying exchanges between partners [source: Lazarus 2005].
  • Map the interpersonal chains between members, for example one partner's withdrawal (B) triggering the other's anxious images (I) [synthesis].
  • Build a shared plan plus individual items [synthesis].
  • With children, use developmentally appropriate language and involve carers [synthesis].
• Example language (illustrative): "I'm not here to decide who is right. When she goes quiet, what pictures go through your mind? And when he starts asking questions, what do you notice in your body?"
• Watch for: One member being cast as "the problem". Keep every member's profile visible.

B1. Establishing the relationship and positive expectations (Garfield, beginning phase)

• Purpose / when: Sessions 1 to 3. This item corresponds to Garfield's chapter "The Beginning Phase of Psychotherapy". His approach rests on factors common to all therapies, and his book also has chapters on the client and the therapist [source: Garfield 1995, Wiley description and TOC]. The steps are [synthesis].
• Steps:
  • Listen actively and convey respect and understanding.
  • Find out how the client expects therapy to work and how long they expect it to take, and correct misconceptions.
  • Express realistic hope.
  • Agree practical arrangements, including the expected number of sessions.
• Example language (illustrative): "Many people with problems like yours improve in a relatively short course. Let's agree what we'll focus on and review after a few sessions."
• Watch for: Mismatched expectations, such as a client expecting long exploratory work or a quick cure. It is working when the client re-engages and attends.

B2. Explanation of the problem and a rationale for treatment [synthesis]

• Purpose / when: End of assessment. Give a plausible, shared explanation that links the problem to a treatment. Whether Garfield names this as a common factor was not confirmed [uncertain].
• Steps:
  1. Summarise the problem in the client's own words.
  2. Offer a simple explanation of what keeps it going.
  3. Link the explanation to the proposed methods.
  4. Check that the client agrees, and revise if they do not.
• Example language (illustrative): "It seems avoiding the situations has kept the fear strong, because you never get to learn they're manageable. So a lot of our work will be gradually facing them, at a pace you agree to."
• Watch for: The client nods without agreeing. Ask them to put the explanation in their own words.

B3. Selecting disorder-specific procedures (Garfield, middle phase)

• Purpose / when: Once the relationship and goals are in place (Garfield's "Middle and Later Phases"). Add methods shown to be effective for the specific disorder, on top of the common factors. Garfield's chapter 5 covers common and specific factors [source: Garfield 1995, Wiley description and TOC]. The choice process below is [synthesis].
• Steps:
  • Identify the main problem.
  • Check current evidence for it, for example exposure-based work for phobias or cognitive-behavioural methods for depression.
  • Pick a procedure you are competent in.
  • Introduce it with a rationale (B2).
  • Monitor progress weekly with a brief measure. Garfield's book has a chapter on evaluating effectiveness; its content is not drawn on [source: Garfield 1995 TOC].
• Example language (illustrative): "For this kind of anxiety there's a well-tested method. Here's how it works and what it would ask of you."
• Watch for: Holding on to a method that is not producing change. Review at about the fourth to sixth session and switch if needed [synthesis].

B4. Working through and consolidating (Garfield, middle phase) [synthesis/uncertain]

• Purpose / when: Mid-therapy. Repeat practice, extend gains to new situations, and deal with obstacles.
• Steps:
  1. Review homework or practice each session.
  2. Reinforce what worked.
  3. Deal with obstacles (see section 5).
  4. Extend the practice to new situations.
• Example language (illustrative): "What went well this week, and where did it get hard?"
• Watch for: Plateaus. Re-check goals and the alliance.

B5. Planned termination (Garfield, terminating phase)

• Purpose / when: The final sessions. Garfield's chapter 8 is "Terminating Psychotherapy" [source: Garfield 1995, Wiley TOC]. The steps are [synthesis]; they are consistent with Lazarus's practice of spacing sessions and then meeting as needed [source: Lazarus 2005].
• Steps:
  • Raise the ending early.
  • Review the gains and attribute them to the client's efforts.
  • Write a plan for setbacks: warning signs, steps to take, and when to return.
  • Space out the last sessions.
  • Offer a follow-up.
• Example language (illustrative): "Let's write down what you've learned that helped most, so you have it if things get harder."
• Watch for: Anxiety or a return of symptoms as the end approaches. Normalise it and refer back to the plan.

5. Handling problems

Grounded in the sources: re-assessing a stalled problem (second-order BASIC I.D., secondary source only), bridging, matching the client's preferred style, and the responses Lazarus describes in the Ben case (listed first below). Lazarus notes that the basic model "does not deal specifically with shifts and revisions" during therapy, and pictures the therapist as a "heatseeking missile" that pursues problems as they arise [source: Lazarus 2005]. Everything not tagged [source] is [synthesis].

• Crisis overtakes the plan [source: Lazarus 2005].
  • Put the Modality Profile on hold and work on the crisis in the modality where it sits. With Ben, relationship crises led to CBT couples sessions, and a bereavement led to grief counselling with the interpersonal modality taking priority.
  • Return to the plan afterwards.
• Hidden or rising depression [source: Lazarus 2005].
  • Re-measure. Ben's Beck Depression Inventory score rose from 11 to 25.
  • Reassess: Lazarus judged the client had been "faking healthy".
  • Refer for a medication assessment; prescribing stays with the prescriber.
• Client about to make a decision you judge harmful [source: Lazarus 2005].
  • Lazarus was willing to take a firm stand on an impulsive job change.
  • Use pros-and-cons balance sheets to slow impulsive choices.
  • Practical meaning [synthesis]: give your view openly, then respect the client's autonomy.
• Family or couple conflict in joint sessions [source: Lazarus 2005].
  • State that you will not take sides.
  • Use role-play and clarifying exchanges.

• Stuck client / plateau.
  • Run a second-order BASIC I.D. on the stuck problem [source: Bhatnagar].
  • Check whether the intervention targets the first link in the client's firing order (tracking).
  • Check whether a biological factor, such as poor sleep, alcohol, side-effects or an untreated medical condition, is blocking progress [synthesis].
  • In Garfield's terms, re-check the relationship and expectations before adding more technique [synthesis].
• Client stays in one modality, for example intellectualising.
  • Bridge: join them in their modality, then move step by step toward the target modality [source: Bhatnagar; GetSelfHelp MMT].
  • Do not confront them head-on [synthesis].
• Resistance to the therapist's style.
  • Go back to the question from the first session about how directive or reflective they want you to be, and adjust [source: GetSelfHelp MMT].
  • A client who rejects homework may accept in-session practice instead [synthesis].
• Overwhelm from a long multimodal plan [synthesis].
  • Cut the active list to two or three targets.
  • Start with the modality most likely to bring early relief.
  • Tell the client the remaining items will be tackled later.
• Non-adherence to homework [synthesis].
  • Ask what got in the way in each modality, for example "I pictured myself failing" (I) or "too tired" (D).
  • Make the task smaller.
  • Rehearse it in session.
  • Check that the task fits the client's preferred modalities from the Structural Profile.
• Ruptures [synthesis].
  • Name the strain openly and ask for the client's view.
  • Take responsibility for your part, for example pushing too fast or choosing a technique that did not fit.
  • Renegotiate the goals and tasks.
  • A technically eclectic therapist who switches techniques often can leave the client feeling processed. Explain each change.
• Incoherence from mixing techniques (a risk specific to these approaches) [synthesis].
  • Keep one written plan and one explanation the client can understand.
  • Do not mix rationales that contradict each other, for example "just accept the feeling" and "dispute the feeling" for the same problem, without explaining why each is used.
  • This applies Lazarus's warning against blending theories, not just techniques [source: C. N. Lazarus 2019].
• Working beyond competence [synthesis].
  • Technical eclecticism invites borrowing procedures such as exposure, trauma processing, hypnosis or sex therapy.
  • Use only those you are trained in; otherwise refer or get supervision.
  • Exposure needs informed consent, a collaborative hierarchy, and screening for medical and psychiatric contraindications.
• Trauma and dissociation [synthesis].
  • If the assessment shows trauma, prioritise safety and stabilisation (grounding, affect-regulation skills) before any memory-focused imagery.
  • Do not use imagery techniques to "uncover" memories.
  • If the client dissociates in session, stop the procedure, orient them to the present through the senses (the S modality), and debrief.
• Medical issues in the D modality [synthesis].
  • Refer physical symptoms for medical assessment.
  • Treat behavioural health routines as adjuncts to medical care, not substitutes for it.
  • Leave medication changes to the prescriber.
• Suicide or self-harm risk [synthesis].
  • Follow standard risk assessment as soon as the history (including any risk items on the MLHI) suggests risk.
  • Put safety planning and lethal-means counselling (safe storage, removal) ahead of the multimodal plan.
  • Increase contact and involve crisis services where indicated.
• Diagnosis-led clients who want "the treatment for X" [synthesis].
  • Show them their individual profile and explain why their plan differs from someone else's with the same label [source: C. N. Lazarus 2019 on looking past the diagnosis].
• Termination difficulties (Garfield frame) [synthesis].
  • Raise the ending early.
  • Treat a return of symptoms as expected.
  • Space out the final sessions and offer follow-up.

Sources

Sources:

• Lazarus, A. A. (2005). The case of "Ben": A flexible, holistic application of multimodal therapy. Pragmatic Case Studies in Psychotherapy, 1(1). Primary; full text.
• Johns Hopkins University Press: The Practice of Multimodal Therapy (Lazarus, 1989). Publisher description and full table of contents.
• Erickson Foundation: EP90 Workshop 05, Multimodal Assessment and Therapy (A. A. Lazarus & C. N. Lazarus). Workshop description and objectives (Modality and Structural Profiles).
• Erickson Foundation: EP05 Workshop 11, Basics of Multimodal Therapy (A. A. Lazarus). Workshop description (bridging and tracking).
• Kobe library record: Brief but Comprehensive Psychotherapy: The Multimodal Way (Lazarus, 1997). Bibliographic record only.
• Wiley: Psychotherapy: An Eclectic-Integrative Approach, 2nd ed. (Garfield, 1995). Description and table of contents.
• Kertész, R. (2005). El enfoque multimodal y las escuelas de psicoterapia. Revista IIPSI, 8(2), 113–127. Secondary; Spanish.
• Grencavage, L. M., & Norcross, J. C. (1990). Where are the commonalities among the therapeutic common factors? Professional Psychology: Research and Practice, 21, 372–378. Cites Garfield; does not list his factors.
• C. N. Lazarus (2015). Lazarus, Arnold. SAGE Encyclopedia of Theory in Counseling and Psychotherapy. Excerpt only.
• OUP: A. A. Lazarus (2005). Multimodal therapy. Handbook of Psychotherapy Integration, 2nd ed.. Chapter landing page only.
• GetSelfHelp: MultiModal Therapy (mmt.htm). Practitioner summary; the page reproduces a 2011 email in which A. A. Lazarus endorses it as clinically accurate.
• GetSelfHelp: Multimodal therapy. The same content, current version.
• Bhatnagar, P. Multimodal Therapy (University of Lucknow teaching notes, PDF). Secondary.
• C. N. Lazarus (2019). Multimodal Therapy: A Unifying Approach to Psychotherapy. Psychology Today.
• C. N. Lazarus & A. A. Lazarus (2015). Multimodal therapy. SAGE Encyclopedia of Theory in Counseling and Psychotherapy (excerpt only).
• Kwee, M. G. T. (1981). Towards the clinical art and science of multimodal psychotherapy. Current Psychological Reviews (abstract only).
• Garfield, S. L. (1995), Google Books (description only).
• Garfield, S. L. (2000). Eclecticism and integration: A personal retrospective view. Journal of Psychotherapy Integration, 10, 341–355 (abstract only).

Further reading (not drawn on) [uncertain for any detail attributed to them]:

• Lazarus, A. A. (1989). The Practice of Multimodal Therapy: Systematic, Comprehensive, and Effective Psychotherapy. Johns Hopkins University Press. Contents list only; chapters not drawn on.
• Lazarus, A. A. (1997). Brief but Comprehensive Psychotherapy: The Multimodal Way. Springer.
• Lazarus, A. A. (2005). Multimodal therapy. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of Psychotherapy Integration (2nd ed.). Oxford University Press.
• Lazarus, A. A., & Lazarus, C. N. (1991; 3rd ed. 1998). Multimodal Life History Inventory. Research Press.
• Garfield, S. L. (1980). Psychotherapy: An Eclectic Approach. Wiley.
• Garfield, S. L. (1989; 2nd ed. 1998). The Practice of Brief Psychotherapy. Wiley.
• Not drawn on: PMC copy of a 2022 BMC Psychology study on eclecticism.