Journal of Psychology and Christianity

2007, Vol. 26, No. 2, 140-150

Copyright 2007 Christian A.ss(X'iation for Psychological Studies

ISSN 0733-4273

A Christian Application ofMultimodal Therapy

Jeffrey p. BjorckFuller Theological Seminary

Graduate School of Psychology

Arnold Lazams' Multimodal Therapy is a model which lends itself readily to work with Christian andnon-Christian clients. It poses few ethical or philosophical obstacles for the Christian therapist, particularlygiven its emphasis on technical eclecticism, whereby the treatment is tailored to the client's unique worldview, personality, and presenting issues. This article presents a brief history of Lazaais' development ofMultimodal Therapy, followed by a current summary of this therapeutic approach. Thereafter, the model iscritiqued regarding its application to Christian approaches, particularly given the growing emphasis onshort-term, empirically supported treatments. Finally, a case study is provided to illustrate one clinician'sChristian application of Multimodal Therapy.

Multimodal therapy was developed by ArnoldA. Lazarus. His prodigious career has includeduniversity faculty appointments at Stanford,Temple, Yale, and finally Rutgers, where he cur-rently is an Emeritus Distinguished Professor ofPsychology (Nelson-Jones, 2001). Lazarus hasbehaviorist roots. Indeed, while completing hisdoctorate under Joseph Wolpe, it was Lazaruswho introduced the terms "behavior therapy"and "behavior therapist" to the li terature(Lazarus, 1958). From 1966 to 1967, he was thedirector of the Behavior Therapy Institute inSausalito, CA (Nelson-Rogers). It was not long,however, before he began to question purebehaviorist approaches as being too narrow. In1966, he wrote about what he called "broadspectrum" vs. "narrow-band" behavior therapy(cited in Lazarus, 1989, p. 7). Then, in 1971 hepublished his book Behavior Therapy andBeyond which has been cited as one of the orig-inal descriptions of a cognitive-behavioral psy-chotherapeutic approach (cited in Lazarus,1989). His motivation for developing his modelwas connected with follow-up assessments offormer clients. As one of the earliest devotees topsychotherapy outcome research, Lazarusobserved high relapse rates for many personsexposed only to pure behavioral techniques. Assuch, he continued to explore the impact ofcombining behavioral and non-behavioral strate-gies. Soon thereafter, Lazarus introduced hisfoundational model, which he initially calledmultimodal behavior therapy (Lazarus, 1973,

Direct all correspondence tojeffrey Bjorck, Ph.D.,Fuller Theological Seminary, Graduate School of Psy-chology, 180 North Oakland Avenue, Pasadena, CA91101, 626-584-5530; jbjorck@fuller.edu.

1976). Later, because of the erroneous assump-tion that his approach was primarily behavioral,he simplified this to multimodal therapy (e.g.,Lazarus, 1989, 2006a). As will become evidentbelow, this model is multimodal not only regard-ing interventions but also assessment.

Multimodal therapy (MMT), with its roots inbehaviorism, has a clear respect for science anddata. This model also recognizes, however, thatpersons can be viewed as more than mere stim-ulus-response mechanisms. Furthermore, MMTemphasizes the need to view each client asunique, potentially representing various excep-tions to any general principles of human func-tion. As such, MMT goes beyond behavioralmethods and involves assessment of othermodalities. This approach might quickly be con-fused with cognitive-behavioral interventions,but Lazarus clearly differentiates MMT from cog-nitive-behavioral and all other therapeutic mod-els. He notes that most therapeutic models havea tripartite focus on behavior, affect, and cogni-tion. In contrast, MMT also emphasizes fourother modalities of human experience, resultingin assessment and intervention across sevenmodalities and their potential interactions(Lazarus, 2006b). In addition to behavior, affect,and cognition, MMT attends to the client's senso-ry responses, mental imagery, interpersonal con-cerns, and biological/physiological issues. Thefirst letters of these seven modalities (behavior,affect, sensation, imagery, cognition, interperson-al relationships, and drugs/biology) convenientlyform an acronym (BASIC l.D.) which is centralto Lazarus' assessment and interventionapproaches (Lazarus, 2007). Introducing the con-cept of the BASIC l.D. to the client provides ameans of establishing good communication

140

JEFFREY P. BJORCK 141

regarding whatever spectrum of problems is pre-sented and also provides the client with a readymeans of quickly grasping the concept of per-sonality as it relates to psychological functioningand the problems at hand.

Lazarus is also quick to acknowledge thatMMT borrows useful material from other models,particularly behavior therapy, rationale-emotivetherapy, and cognitive therapy. He notes severalfactors, however, which distinguish MMT fromthese and other models. In addition to theunique seven-modality approach of the BASICI.D., he notes MMT's use of a second-orderBASIC I.D., modality profiles, structural profiles,bridging techniques, and tracking the modalityfiring order (Lazarus, 2007). These distinctivefeatures will each be discussed below. First,however, it is important to note two of MMT'sfundamental principals.

One of Lazaais' central tenets is the concept oftechnical eclecticism (Lazarus, 2006a). Thisshould not be confused with the more commonunsystematic eclecticism, whereby the therapisthaphazardly uses components of various theo-ries and their related interventions in a purelypragmatic way. Technical eclecticism also differsfrom theoretical eclecticism, whereby the clini-cian combines components of different theoriesas a basis for using related interventions(Lazarus, 2007). Lazarus consistently opposesunsystematic approaches and also argues thattheoretical eclecticism can at times be unprof-itable or even counterproductive, particularlywhen such theories actually posit opposingviews (Lazarus, 1996). In contrast, technicaleclecticism refers to the process of utilizing tech-niques derived from various theoretical orienta-tions while maintaining a non-redundant, unifiedtheoretical focus. Lazarus' own orientation issquarely based on social cognitive theory (Ban-dura, 1977, 1986) while also tapping general sys-tem theory (Bertalanffy, 1974; Buckley, 1967)and group and communications theory (Wat-zlawick, Weakland, & Fisch, 1974). He arguesthat these three influences are not redundantand form a complementary singular approach(Lazams, 2007). As such, the technically eclecticclinician adopts various techniques while notnecessarily ascribing to the theories from whichthey emerged. Lazarus qualifies this approach byproposing that well-documented, empiricallysupported treatments should always be the firstcourse of action (Lazarus, 2006a). When suchapproaches do not prove faiitful or when they

are not available, however, the multimodal thera-pist's technically eclectic approach provides awealth of interventions from which to choose.

Another foundational concept for Lazarus isthe idea of thresholds (Lazarus, 2007). He notesthe importance and strength of genetic influ-ences and emphasizes that such factors can beobserved physiologically in the form of individu-als' differential reactions to negative stimuli (e.g.,pain, stress, and other environmental factors).Nelson-Jones (2001) summarizes this position:"People whose autonomic nervous systems arestable, which usually indicates high thresholds tomany events, have a different personality patternand are likely to be less anxiety-prone thanthose whose autonomic reactions are labile,which usually correlates with low thresholds" (p.364). Thresholds can therefore necessarily limitthe effectiveness of therapeutic interventions. Forexample, a clinician skilled in pain managementtechniques may help a client to improve paintolerance, but if that client has a very low painthreshold, optimal pain management will not bepossible no matter how skilled the clinician is.The concept of thresholds provides an importantcontext for understanding each of the distinctivefeatures of MMT, which will now be reviewed.

Distinctive Features of MMTThe Structural Profile employed in MMT is

clearly tied to the concept of thresholds. Anempirically supported Structural Profile Inventory(e.g., Herman, 1993; Lazarus, 2006a) is availablefor assessing the extent to which clients' personal-ities can be reflected by variance across the sevenBASIC LD. modalities of human experience. Relat-ing the modalities to the concept of thresholds,Lazarus proposes that different clients will bemore likely to react to some modalities than oth-ers, and that such different response tendencieswill differ from client to client (Lazams, 2007). Assuch, he notes that noncompliance issues thatoften are interpreted as the client's resistance mayactually reflect the therapist's resistance (Lazams,2006a). For example, attempting to force a clientinto a cognitive-behavioral framework may provecounterproductive if that client actually scores lowregarding the behavioral and cognitive modalities.Similady, including imagery in relaxation trainingmay render success less likely for a client whoassesses her imagination as poor. Conversely,learning which modalities are preferred for a givenclient and then focusing on interventions in thosemodalities can help to optimize treatment success.

142 MULTIMODAL THERAPY

The BASIC I.D. also serves as the stmcture forinitial problem assessment via the modality pro-file. This is derived from the 15-page MultimodalLife History Inventory (Lazarus, 2006a). Thisinventory includes a series of rating scales andopen questions organized across the sevenmodalities. Given its length, it also serves toassess the client's motivation for treatment. Afterthe clinician reviews this information and follow-ing initial clinical interviews, a modality profilecan be created consisting of a chart listing eachmodality, problems cited in each modality, andrelated proposed treatments. This problem list canbe reviewed with the client as a psychoeducation-al tool, and it can also be revised as treatmentprogresses (Lazams, 2007). Using this assessmenttool helps the clinician to avoid missing specificconcerns which might otherwise obstmct treat-ment progress. This multimodal framework thenprovides a basis for utilizing unique interventiontechniques, bridging and tracking.

Bridging is a useful technique which can helpclients to access previously blocked modalities ofexperience. This intervention addresses a client'savoidance of particular modalities (e.g., affect)by first acknowledging the client's preferredmodality (e.g., thinking) and then bridging backto the avoided modality through an intermediate,less aversive modality. Thus, for example, aclient who responds, "I think that..." whenasked, "How do you feel>" is not badgered withpersistent refocus on feelings. Rather, the multi-modal clinician acknowledges the client's prefer-ence for reasoning and allows him to pursue histhesis regarding a given problem. By doing so,the client feels heard and validated. Next, theclinician will gently raise questions in anotherpreferred or neutral modality. For example, ifimagery is another of the client's preferredmodalities, he might be asked to report whateverimages come to mind as he thinks about theproblem. Then, while describing the images, theclinician could ask what feelings were arousedby these images, at which point Lazams propos-es it is far more probable that the client willrespond affectively (Lazarus, 2006a). Thus, byacknowledging preferred modalities rather thanconfronting them, and by then invoking otherpreferred or neutral modalities, this bridgingtechnique can help the client to engage inhealthy experience regarding a previously avoid-ed modality. This in turn can reduce the likeli-hood that clients will appear resistant. Incontrast, as previously stated, therapists who

insist on client compliance with a givenapproach may lose the client due to resistance,but this resistance belongs to the therapist!

Tracking is an intervention which also capital-izes on the BASIC I.D. as a multimodalapproach. Lazams suggests that individuals typi-cally have a modality firing order that is general-ly consistent across situations and thus can helpin elucidating the nature of symptoms and prob-lems for which the client cannot readily deter-mine a cause (Lazarus, 2006a). For example, adepressed client whose symptoms cyclicallyworsen "for no reason" might identify that suchsymptomatic exacerbation actually begins withbodily sensations (S) of fatigue or muscle sore-ness upon waking in the morning. These sensa-tions might trigger cognitions (C) such as "Thiswill probably be a really bad day," and/or "I willprobably always be depressed." The negativethoughts might then prompt depressive behavior(B) such as remaining in bed all day, whichleads to worsening affect (A). By identifying thisS-C-B-A firing order, treatment can proceed toaddress the problem of worsening symptoms atits start. The clinician might suggest exploringpossible reasons for morning fatigue or soreness(e.g., poor sleep hygiene, caffeine abuse, badmattress), and also help the client to counter thenegative thoughts with more reasonable ones(e.g., "This day represents an opportunity"and/or "soreness does not equal depression, andstretching helps.") Additionally, suggesting amorning routine of stretching and taking a briefwalk before breakfast could serve not only tocounteract soreness but also mobilize adaptivebehaviors (e.g., not remaining in bed).

The final distinctive feature of MMT involvesuse of a second-order BASIC I.D., which can beemployed when success is not achieved usingthe standard BASIC I.D. The second-order BASICI.D. provides a more thorough assessment of anunresponsive problem. For example , ifdepressed mood does not respond to interven-tions suggested by the initial BASIC I.D., theclinician can then ask the client to think onlyabout her depressed mood and generate associa-tions in terms of all seven of the modalities(Lazams, 2007). Possible responses might be asfollows: withdrawal (B); sorrow and worry (A);headache (S); image of rain against the window(I); thought of a possible brain tumor (C); loneli-ness (I); family history of cancer (D). In thishypothetical case, the second-order BASIC I.D.reveals that the client associates depressed mood

JEFFREY P. BJORCK 143

with the possible threat of a brain tumor, herheadaches, and her family history of cancer. Insuch a case, recommending referral for a brainMRI might eradicate this block to treatment, andprogress can resume once negative results areobtained and the client's fears are allayed.

Multimodal PsychotherapyAs should be clear from the preceding conver-

sation, MMT places great emphasis on assess-ment with respect to personality (e.g., stmcturalprofiles), comprehensive problem inventories(e.g., modality profiles), processes underlyingsymptoms (e.g., tracking of firing orders), andmore focused examination of unresponsiveproblems (e.g., second-order BASIC I.D.s). Thus,the initial sessions are focused on assessmentand evaluation, but the intake need not be com-pleted before interventions are used. Indeed, uti-lizing appropriate interventions during initialsessions, particulady those resulting in symptomrelief, can help to build the therapeutic alliance(Lazams, 2006a).

In addition to initial assessment, "ongoingevaluations of progress are integral to multi-modal therapy" (p. 376, Nelson-Jones, 2001).Such evaluations are done within the context ofthe therapeutic relationship, which emphasizescollaboration and parity. Indeed, in recent years,Lazarus and others (e.g., Lazarus & Zur, 2002)have argued not only for parity but also for theelimination of universal taboos regarding all dualrelationships, particularly noting the importantdifference between boundary crossings andboundary violations; "Boundary violations referto actions on the part of the therapist that areharmful...[such as]...sexual or financial exploita-tion of clients. A boundary crossing is a benignand often beneficial departure from traditionaltherapeutic settings or constraints" (p. 6). Whilebeing careful to avoid boundary violations, themultimodal therapist will be flexible inapproaching the therapeutic process, taking theunique considerations of each client into consid-eration (Lazams, 2006a). As one straightforwardexample, the multimodal therapist will optimizein vivo exposure techniques with an anxiousclient by accompanying the client to the specificfeared environment in question (e.g., restaurant,shopping mall, car, etc.).

When considering intervention selection andthe resulting appearance of the therapeutic pro-cess, it is essential to remember the technicallyeclectic nature of MMT. The Multimodal Life

History Inventory (Lazarus, 2006a) asks clientstheir expectations regarding the nature andduration of therapy, as well as the qualities ofthe ideal therapist. This information helps thetherapist to match the style of the client. Giventhis information, it is possible that the samemultimodal therapist seeing four clients in suc-cession might use Rogerian, Gestalt, psychody-namic, and cognitive techniques in the fourrespective sessions. Lazarus favors interventionswith clear empirical support (Lazarus, 2006a),but when these are not available or do notprove helpful, MMT proposes that interventionsshould be selected in response to the particularclient's modality and/or structural profiles.Whereas MMT advocates competence in a widearray of techniques (Lazarus, 1989; Lazarus,2007), such interventions are to be used "spar-ingly according to the assessed needs of individ-ual clients" (Nelson-Jones, 2001, p. 379).

Traditionally, MMT typically involved 50 week-ly sessions; but with the advent of managedcare, Lazarus illustrated that a brief approach (10to 12 sessions) is completely feasible (Lazams,1989; Lazarus, 2006a). Indeed, MMT not onlylends itself well to shon-term models but also tocrisis intervention (Eskapa, cited in Lazarus,2007). In addition, MMT has been shown to beuseful with a variety of specific applications,including marital therapy, sex therapy, childtherapy, group therapy, and therapy with persis-tently mentally ill persons (Lazarus, 1989). Inshort, MMT presents as a very versatile therapeu-tic model that lends itself well to short-termand/or longer-term treatment models with abroad variety of problems and populations.

Empirical SupportWhereas MMT has not yet been named as an

empirically supported treatment (EST), therehave been numerous case studies over the yearsdocumenting its efficacy (e.g., Breunlin, 1980;Bmnell, 1978; Keat, 1996; Lazarus, 1985; Lazams,2005; Martin-Causey & Hinkle, 1995; Richard,1999). As noted previously, MMT might beviewed as a flexible expansion of empiricallysupported cognitive and/or behavioral treat-ments, given MMT's focus on seven modalitiesrather than only three (cognition, behavior, andaffect); but formal assessment of MMT as an ESThas not yet been published. One study did pro-vide some indirect empirical support for MMT.Herman and Roudebush (1998) found thatgreater matching between therapist and client

144 MULTIMODAL THERAPY

regarding modality orientation preferences led tobetter therapy outcomes. (For a current reviewof MMT, see Lazaais, 2007).

One Christian's Application andCritique of MMT

In my small outpatient private practice, I treatboth non-Christian and Christian individuals,couples, and occasionally families. I was firstexposed to MMT over 22 years ago, when as agraduate student I attended a day-long seminartaught by Dr. Lazaais. My immediate attraction tohis approach may have been partially due to itsaction-oriented, multi-level, problem-focusedapproach which was a good fit for my ADHD-prone personality. This approach gave me per-mission to focus on many things at once, whichis actually easier for me than focusing on onething! Thus, I would note that MMT might not bea satisfying approach for clinicians preferring aslower paced, less active style of therapy focus-ing much on the relationship and little on tech-niques. Indeed, Lazams (2006a) views a primaryfocus on relationship as necessary but rarely suf-ficient.

Whereas I do not approach MMT solely from asocial cognitive and/or systems theory perspec-tive as Lazams (2007) does, I concur with himthat a unified theoretical focus is caicial. A thor-ough description of my own theoretical orienta-tion is beyond the scope of this article. In brief,it does include a respect for all the componentsof Lazarus' blended theory when consideringconscious and/or intentional behaviors. My ori-entation also encompasses the concept ofunconscious processes, however, which I viewtheologically as manifestations of original sin.Specifically, I would propose that original sinmight readily be summarized as the innate desireto perceive oneself as completely sufficient, withno need of God, others, or any self-change.Given that reality continually disproves thisdesired perception and its concomitant wish toperceive oneself as completely in control, Ibelieve that anxious walls of denial are uncon-sciously constmcted to block out contradictionsof self-sufficiency and maintain illusions of con-trol (Bjorck, 1995). From this vantage point,progress in therapy can be measured by theclient's ability to identify these walls, dismantlethem (exchanging unrealistic anxiety for reason-able and guilt-free sorrow over the fact that alldecisions involve loss), and embrace human lim-its as God's gifts. Doing so permits the client to

move towards increasing peace, self-acceptance,and dependence on God while maintaining andenhancing reasonable human agency andresponsibility as two other gifts from God.

Whereas my theory diverges from Lazarus'(2007), I fully value and maintain his technicallyeclectic approach. I also continue to use theStaictural Profile Inventory (SPI; Lazaais, 2006a)with every new client, presenting the scores in abar chart as a means of providing feedback.Whereas I also use more detailed assessment(e.g., the Millon Clinical Multiaxial Inventory-III;Millon, 1994), I have found that the SPI is oftenmore helpful in communicating to the client thatI understand them well. This often helps toengender hope and enhance motivation. It isespecially useful when working with couples.Not only can comparison of the two staicturalprofiles provide insights, but asking each partneralso to complete a profile for the other can illus-trate the degree to which each partner knowsthe other (Lazams, 1989).

Lazams' technically eclectic, problem-focusedapproach to therapy fits well with my own viewsregarding the need to identify functional impair-ments as treatment foci, with the client and notthe therapist as the focus of therapeutic goals(Bjorck, Brown, & Goodman, 2000). Thus, Iagree that goals targeting the client's willingnessand ability to progress through mandated stepsof a particular theoretical framework may actual-ly be more for the benefit of the therapist thanthe client. Indeed, clients who fail to comply insuch cases may erroneously be characterized asresistant (which itself may be a self-fulfillingprophesy of a given theoretical orientation).

Lazams' argument for technical eclecticism alsostrongly resonates with my own Christian per-spective. Indeed, the Apostle Paul noted that hewould become "all things to all people" in orderto communicate the Gospel most effectively (ICorinthians 9:22). In doing so, Paul modeledwhat Lazarus calls being an "authenticchameleon" (Lazaais, 2006a, p. 14). Rather thanforcing the Gospel on diverse people with a uni-tary approach, Paul modified his presentations inaccordance with the culture, beliefs, and prac-tices of his audience. Likewise, Lazarus notes,"Effective psychotherapists are constantly onguard against fitting the patient to the treatment.A primary purpose ... is ... to fit the treatment tothe patient" (Lazams, 1989, 63). As such, MMTconsiders all aspects of diversity, going beyondbasic demographics.

JEFFREY P. BJORCK 145

Having said this, and noting the American Psy-chological Association's (1991 2002) call, to con-sider religious and/or spiritual beliefs as animportant diversity issue, MMT's technicallyeclectic approach is particulady suited to work-ing with Christian clients. Such clients' worldviews will include a variety of religious premisesthat may inform a variety of modalities acrossthe BASIG I.D. As perhaps the most obviousexample, belief in God as a real, relational beingwill typically be a primary cognitive premise thathas ramifications for all other cognitions. Godwill probably also be considered with respect toother modalities, for example, as a key figure inthe client's interpersonal network (e.g., Fiala,Bjorck, & Gorsuch, 2002). As another example offaith informing the BASIC I.D., imagery exercisesmight be contraindicated for a client who viewsimagery as a prohibited non-Christian religiouspractice. Diversity concerns should also gobeyond simply determining whether or not aclient is a Christian and include consideration ofthe wide variety of unique denominationalbeliefs among Christians. Given that such specif-ic beliefs can influence all aspects of the client'sfaith and world view (Trice & Bjorck, 2006), pre-cisely tailoring the treatment to the individualcan be even more important; and MMT providesa useful means for doing this.

When considering MMT from a Christian (orany spiritual) perspective, one obvious questionconcerns the lack of a spiritual modality. Tan(1991) has suggested that MMT "ignores the cai-cial spiritual dimension of human life and experi-ence" (p. 39). To address this concern. Tanproposes that a Christian approach to MMTshould thus add "S" to the BASIC I.D. as an eighthmodality. In response to such critique, Lazarusargues that adding an eighth modality is redun-dant. In earlier years, he suggested that spiritualitycould be accounted for parsimoniously as thecombination of strong cognitions and strong affect(A. Lazams, personal communication, November1, 1985). More recently, he has proposed that thespiritual dimension is typically a combination ofstrong cognitions (beliefs), which are frequentlyexperienced together with strong imagery andsensations (Lazarus, 2006a). His description ofspirituality is laudable in its avoidance of redun-dancy, but two rebuttals are possible.

First, given the arbitrary nature of all psycholog-ical constaicts (Nunnally & Bernstein, 1994), it isimportant to note that the seven modalities, whilemeaningful, should not be reified. While very

useful, the modalities in MMT have considerableoverlap. For example, one could certainly arguethat images, as mental representations, are simplya subset of cognitions. Likewise, emotions can beoperationally defined as cognitively interpretedsensations and perceptions (e.g., R. Lazarus,1991). This can explain, for example, why rapidheart beat and shallow respirations can just asreadily signal fear as joyful exuberance dependingupon the cognitive interpretation. Thus, onemight argue for eliminating both imagery andaffect, as being subsumed in the combination ofcognition and sensation. This ignores the utility ofall four modality labels, however, as useful toolsfor meaningful communication between therapistand client. Similar utility can result in allocating aseparate modality for spirituality, however, partic-ularly for Christian clients.

The second rebuttal concerns the Christianwodd view that God is a real Person, and notsimply a projection of one's personality or unmetwishes. For clients with this spiritual world view,the message that spirituality can be reduced to asimple emanation of self (e.g., strong beliefs orsensations) may possibly cause a rift in the thera-peutic relationship. Indeed, doing so might besaid to be fitting the client to the treatment, theantithesis of MMT.

Clearly, as a Christian psychologist whobelieves in a Personal God, I have no difficultyavoiding the pitfalls of communicating to a clientthat spirituality should be relegated to thedomain of projected cognition, imagery, affect,and/or sensation. (Conversely, I would notemphasize spirituality to a client who expressesno spiritual interests, and I would make sure torespect any client's world view.) Typically, how-ever, I do not add "S" to the BASIC I.D. whencommunicating feedback to Christian clients.Whereas this difference from Tan (1991) isalmost entirely semantic, I prefer to conceptual-ize God and the spiritual realm as completelyencompassing all seven modalities. To relegatethe spiritual to only one modality can potentiallycommunicate that it is not related to the BASICI.D. (and thus must be added). I do, however,always include a spiritual history as part ofintakes (e.g., Bjorck, 1997; Tan, 1996), which hasalso been endorsed by sources outside Christiancircles (e.g.. Sue & Sue, 1999).

Before using any therapeutic approach, it isethically important to consider whether it isappropriate for a given client in a given circum-stance. When considering MMT, such questions

146 MULTIMODAL THERAPY

are even more central given their relevance totechnical eclecticism. As Lazaais notes, "Techni-cal eclectics try to answer the basic pragmaticquestion: What works for whom and underwhich particular circumstances" (Lazarus, 1989,p. 5). With this in mind, I would suggest that theflexibility of MMT assures its appropriate use invirtually every instance where the concept of theBASIG I.D. can be cognitively grasped by theclient/clients. As such, this approach wouldrequire caution when working with those whoseintellectual functioning is markedly below aver-age. In addition, given the clinician's activestance and frequently simultaneous attention tomultiple areas, MMT might be less effective forclients who are merely seeking solace and a safeplace to vent rather than assistance with address-ing self-change. As such, those clients who arehighly narcissistic and/or otherwise highly defen-sive can represent greater challenges. It shouldbe noted, however, that the competent multi-modal therapist will adjust her/his approachaccordingly, perhaps even resorting to the prima-ry utilization of Rogerian (1951) techniques for aconsiderable interval, in order to enhance theclient's comfort levels and willingness to considertangible constaictive changes (Lazaais, 2007).

Case ExampleTo illustrate my use of MMT, I will present a

fictional case based on a conglomeration ofmany cases I have seen over the years. Mike wasa 27-year-old African-American male who wasreferred by an insurance company handlingWorker's Compensation claims. He lived with hiswife and two sons, ages 2 and 4. When I methim, he had worked at the same bank sincegraduating from community college and hadserved as a teller for the past 5 years. Threeweeks before his initial visit with me, this bankhad been robbed right before closing. Themasked robber had run in, jumped Mike'scounter, said "how ya doin'?" and then haddrawn a gun, pressing it into the side of Mike'shead. He first forced Mike to his knees while heordered all those in the bank to lie down. Then,Mike was told to collect all available money,while the robber (a foot taller than Mike)clutched Mike's collar with his left hand andkept the gun jammed against Mike's head withhis right. At one point early on, a customerscreamed and the gunman fired a warning shotinto the ceiling, immediately and forcefullyreturning the gun to Mike's temple. After collect-

ing the money, the robber pushed Mike to thefloor, told him not to move, and ran from thebuilding to a waiting car that sped away.

Throughout the incident, Mike had continuallyexperienced images of his wife and children andhad silently begged God to protect his life.Immediately after the robber had left the build-ing, Mike experienced some relief but also feltsomewhat "numb." He felt himself "goingthrough the motions" as he was interviewed bypolice, who commented on how calm and how"lucky" he was. As Mike drove home, hethanked God for protecting his life but he wastroubled by the fact that "it was like the wholething had been on TV, not real." After dinner,when the children were put to bed, he told hiswife about the event, omitting many details"because I did not want to stress her out." Healso told her that the bank would be installingbullet-proof glass the next day and hiring anarmed guard (which was tme). That night, hissleep was interrupted by nightmares in whichthe gunman repeatedly slammed the gun intoMike's head and forced him to his knees. Heawoke tired and "still feeling numb." Upon arriv-ing at work, he was barraged by well-meaningco-workers asking him repeatedly how he wasdoing. "I kept saying I was OK, but more andmore, I didn't even believe myself." Then, whena customer accidentally dropped a laptop with aloud crash, Mike yelled and dropped to the floor"in a cold sweat." Seeing people stare at him ashe rose from the floor, he walked quickly out ofthe front doors, "and I haven't been able to gonear the bank since then. I don't feel numb ariy-more. I just feel lousy."

Mike initially presented with symptoms meet-ing criteria for a marked Acute Stress Disorder.When assessing his problems with respect to theBASIC I.D., his chief complaints included: (B)avoidance of the bank, inability to button his col-lar or wear a tight tie, and heightened startleresponse, difficulty resuming sleep after awakingfrom nightmares; (A) anxious and depressedmood, guilt, shame; (S) hypersensitivity to any-thing touching his neck; (I) nightmares of thetrauma, flashbacks of the gunman's masked face;(C) repeating thoughts, such as, "I should havedisabled him before he drew his gun," "I can'tprotect myself or my family," "What's to stop himfrom coming back?" "What did I do to deservethis?" "A person with more faith would be able tohandle this;" (I) discomfort around friends due tocontinual questions and even some discomfort

JEFFREY P. BJORCK 147

around his wife, feeling somewhat distant fromGod; and (D) fatigue and headaches.

As discussed above, I do not add a separate"S" dimension (spirituality), but my conceptual-ization of any case is permeated by the spiritual.I typically look for ways in which spiritual issuesare relevant for the client, however, rather thanimposing on the client my premise that spirituali-ty permeates all else. Mike viewed his behavioralproblems (B) as spiritually problematic only tothe extent that they reflected his current inabilityto "tmst God enough to just go back to work."His avoidance of work compounded his feelings(A) of guilt and shame, which had spiritual over-tones as well (e.g., "not having enough faith").He drew no spiritual connections to his hyper-sensitivity regarding his neck (S), so this issuewas not framed in spiritual terms. His nightmares(I), however, were disturbing in that theyinvolved "no sense that God was with me."Mike's spiritual concerns were most clearlyapparent in the cognitive (G) modality, where histroubling thoughts had strong spiritual over-tones. Interpersonally (I), Mike's feeling distantfrom God also caused him distress. Finally, hisfatigue and headaches (D) seemed like naturalconsequences to Mike, and he did not associatethese with his spiritual outlook.

Mike's structural profile showed particularlystrong preference for imagery and cognitionmodalities, with medium preference for behav-ior, affect, interpersonal, and dmgs/biology andlower preference for sensation. Whereas headmitted he was uncomfortable about "spilling[his] guts to a stranger," he also reported feelingbetter knowing that I shared his faith (he hadasked for a referral to a Christian psychologist).Because he also quickly confessed guilty feelingsfor "needing to see a shrink," I assured him thatmy job was to "work myself out of a job andhave you back on your own ASAP." I alsoreminded him that he was the "expert" on him-self and thanked him for sharing his expertise inthe form of the detailed and helpful informationhe had provided me. The parity of this collabo-rative approach immediately seemed to reducehis embarrassment about being in treatment, andtogether we worked to prioritize his problems.We also addressed issues of race and culture,especially given that I and the gunman wereCaucasian. Mike chuckled and responded, "Aslong as you don't wear a mask, I won't have anyproblem." I supportively responded that, beyondhaving no problem, I hoped that treatment

would be a culturally affirming experience. Tothis end, I invited him to help me fully under-stand his culture (via instruction, correction, clar-ification, etc.) and its impact on our worktogether, as yet another area of his expertise.

Mike identified his thoughts and images to bethe most troubling problems. Next in line werehis need to return to work and his dysphoricmood. Treatment began with a primary focus onthese four areas. First, however, some stop-gapmeasures were put in place regarding othersymptoms. For example, Mike reported thataspirin eliminated his headaches, so his moder-ate use of this medicine was encouraged.Because he had just had a company physical, nophysician referrals were made. I also educatedhim regarding sleep hygiene and provided himwith a relaxation tape to use at home beforebed. His aspirin use quickly subsided, and Mikereported that he also found the tape helpful dur-ing the day "if I get really antsy." With theseinterventions in place, treatment proceeded.

With regard to his negative thoughts, Iobserved that two of his predominant thoughtshad clear spiritual overtones ("What did I do todeserve this?" "A person with more faith wouldbe able to handle this."). As such, using Lazaais'(1989) correcting misconceptions intervention,therapy focused on helping him see how hisown Christian faith actually did not advocate foran automatic direct link between behavior andmisfortune, but rather implied that bad thingscould simply happen (e.g., the life of Job, theBeatitudes, the martyrs through history). I alsoeducated him regarding how normative hisresponses were to his life-threatening trauma,noting that even the most spiritual people canexperience such symptoms in response to what Itermed "such evil events." At the same time, Ibegan to introduce the concept of illusory con-trol (Bjorck, 1997), and helped him to see howhis self-blaming statements (e.g., "I should havedisabled him before he drew his gun," "What didI do to deserve this?") might serve as attempts todeny his human limitations, which entailed beingtoo hard on himself. Moreover, I guided him toseeing that denial of reasonable limits (e.g., "Ishould be able to instantly stop a gunman evenbefore I know he has a gun.") comes at anunreasonable cost (e.g., false guilt over the "fail-ure" to stop the gunman). Similarly, regardinghis thought that he had insufficient faith in God,I helped him see that most people's lack of fearabout going to work is not primarily due to

148 MULTIMODAL THERAPY

strong faith in God; but rather is due to theunstated assumption that they can guaranteetheir safety simply by being careful. In this light,Mike was able to see that his life circumstanceshad shattered his illusory assumptions Qanoff-Bulman, 1992) and now prevented him fromhaving such an illusion of control about beingsafe at work. As such, his willingness to return towork would indeed signify true faith in God,whereas going to work for most people wouldnot involve fear or faith and primarily signify theillusion of presumed safety. Finally, given hisquestion regarding "deserving" this event, Ibegan to encourage Mike to explore his ownGod concept regarding the cognitive, affective,and interpersonal realms. In doing so, Mike wasable to identify that he had "always kind ofviewed God as a distant employer that I wassupposed to please, who would reward me if Idid well but punish me if I failed."

In addition, Mike came to the awareness that"God must have loved me to keep me alive thatday." Whereas I personally believed that Godwould have loved Mike just as much even ifMike had been killed, I did not impose this viewgiven that Mike's "life-saving" reframe of theevent was helping him move forward. I did,however, encourage Mike to consider the 25'^Psalm's statement that God is with him evenwhen he walks through, not around, the valleyof the shadow of death. He found this helpful,commenting that "I guess I know better now thatGod is always with me, even in hard times."

Over the weeks, referring Mike to other scrip-tural texts (i.e., bibliotherapy, Lazaais, 1989) anddisctissing them resulted in his increasingly beingable to exchange his stern view of God for amore personal God who loved him independent-ly of his performance. For example, he appreciat-ed Deuteronomy 31:6-8, in which Godencouraged Joshua to be strong and not fearbecause God would never leave him nor forsakehim. In processing this text, Mike was relievedand encouraged by the realization that Godwould not have needed to encourage Joshua tobe strong if Joshua had already been fearless.Mike also found comfort in the fact that, whereasGod promised never to leave nor forsake Joshua,this did not mean that bad things never happenedor that Joshua always succeeded at what he tried.In response, Mike commented, "I guess God real-ly understands that we are afraid or else hewouldn't remind us to taist Him; and if bad thingsstill happened to Joshua, then I guess my robbery

doesn't mean that God doesn't love me or that Iautomatically sinned or something." In addition,he found new meaning in Philippians 4:6 regard-ing the peace that passes understanding. I helpedhim explore the implications of God's peaceexceeding human understanding, suggesting thatthis premise implies it is completely understand-able for humans not to have supernatural peaceautomatically. In response, he said, "I guess Godknows that humans have a lot to be anxiousabout if we try to make things all up to us! Iguess I was trying to make my robbery all up tome when there really wasn't anything I could'vedone about it." Finally, the admonition (I Peter3:7) to cast all his cares on God because Godcares for him was particularly useful. After pro-cessing this passage in session, Mike reflected,"The robbery puts this verse in a whole new lightfor me." Specifically, he was able to see that "cast-ing his cares" could be restated as "accepting therobbery as something beyond my control and giv-ing it to God," rather than continually trying tomentally castigate himself for what he could haveor should have done differently.

Mike's nightmares and flashbacks also troubledhim greatly, and given his preference for theimagery modality, therapy focused here as well.The concept of illusory control was again incor-porated, with the suggestion that nightmares andflashbacks might be his unintentional repeatedattempts to replay the event but do it differently.Mike resonated with this reframe, and with alaugh, remarked, "I guess that would be likewatching a movie over and over to see if it endsdifferently." Using backward time projection(Lazarus, 1989) as an imagery intervention, Mikewas able to go back to the actual event and staywith "Mike" (himselO through the entire situa-tion. Mike imagined that only the "Mike" fromthe past could see or hear him in this time travelexercise. Mike imagined himself standing rightnext to the robber with his hand gently on"Mike's" shoulder, reassuring "Mike" that he defi-nitely would not be hurt in this situation and thatGod had chosen to keep him safe. Mike alsoencouraged "Mike" not to blame himself forchoosing not to try disabling the gunman, rea-soning that "even a gramma with a gun wins." Inaddition, Mike pointed out that "because youtook the stress of doing nothing, your wife andkids still have a husband and father." During thisimagery exercise, Mike reported vivid images,which he experienced "in ftill color, except thistime, I knew that I would be OK in the end and

JEFFREY P. BJORCK 149

that God was with me." Mike also experiencedhis first tears "in a long time" during this exerciseand reported that it was "like a scar was heal-ing." Using self-instructional training (Lazarus,1989), I suggested that Mike make the followingstatement: "The more I accept this event as apart of my story, the less I will have to keep re-reading this chapter." Philippians A:6 (as dis-cussed above) also helped him accept thetrauma. In the ensuing weeks, he spoke thisstatement and/or recited Philippians 4:6 to him-self upon waking from nightmares and/or havingflashbacks, and both disturbances were reducedand eventually eliminated over time.

Fortunately, and not surprisingly, Mike's emo-tional symptoms decreased as a result of theinterventions described above. His hypervigi-lance, however, was still an issue whenever hedrove near the bank. Thus, behavioral techniquessuch as in vivo counterconditioning (Lazarus,2007) were employed midway through treatment,whereby I accompanied Mike on walks thatbrought him increasingly closer to the bank andeventually into the bank itself (while I waited justoutside). This progressed to his making the tripsalone while talking to me via his cell phone, andultimately resulted in his full return to work. Sim-ilar counterconditioning exercises helped Mikeresolve his aversion to anything being snug onhis neck (e.g., his tie). This represented anotheraccomplishment, particularly given the bank's"ties are required" dress code.

Resuming work encouraged Mike greatly, andsupport from his co-workers served to furtherbolster his mood. By this time, his relationshipwith his wife had gotten "back to normal," withthe help of two sessions one month apart whereI requested that his wife accompany him. Duringthose two conjoint sessions, I focused on nor-malizing Mike's situation and offered them somestrategies for increased communication andmutual support. Given the extant strength oftheir marriage, these two sessions sufficed.Including these two, Mike's MMT involved 30sessions, with twice weekly sessions for the firsttwo weeks to address his crisis, followed byweekly sessions for 20 weeks, 5 bi-weekly ses-sions after his return to work, and a final follow-up session after one month. Given the severityof his trauma and resulting symptoms, it isunlikely that short-term (e.g., 10 to 12 sessions)would have sufficed, although such a time-limit-ed approach can be very useful for more moder-ate clinical concerns.

Conctusion

MMT is a versatile model for addressing theimique therapeutic concerns of Christian clients(e.g., God concept, spiritual concerns, etc.).Whereas it has not yet been identified as anempirically supported treatment, MMT's empha-sis on using empirically supported technicjues(e.g., cognitive-behavioral interventions), togeth-er with multiple documented MMT case studies,suggest that this model is useful in facilitatingpositive therapeutic outcomes. It is also suffi-ciently flexible to lend itself readily to use byclinicians who hold Christian beliefs and values.Whereas Lazarus (2006a) does not view spiritual-ity as a separate modality, it can be argued that atechnically eclectic approach must address spiri-tuality when addressing Christian clients or riskforcing a fit of the treatment to the client. Giventhese qualifications, Christian clinicians seekingtherapeutic orientations well-suited to today'sshort-term treatment protocols should give MMTserious consideration.

ReferencesAmerican Psychological Association. (1991). Guide-

lines for providers of psychological services io eihnic,iinquistic, and culiurally diverse poputaiions. Washing-ton, DC: Author.

American Psychological Association. (2002). Ethicalprincipals of psychologists and code of conduct. Amer-ican Psychologisi, 57, 1060-1073.

Bandura, A. (1977). Social learning theory. Engle-wood Cliffs, NJ: Prentice-Hall.

Bandura, A. (1986). Social foundaiions of ihoughiand aciion: A sociai cogniiive iheory. Englewood Cliffs,NJ: Prentice-Hall.

Bertalanffy, L. von (1974). General systems theory andpsychiatry. In S. Arieti (Ed.)., American handhook ofpsy-chiairy, I, (pp. 1095-1117). New York, NY: Basic Books.

Bjorck, J. P. (1995). A self-centered perspective onMclntosh's religious schema. Iniernaiional Journal forihe Psychology of Religion, 5, 23-29.

Bjorck, J. P. (1997). Religiousness and coping: Impli-cations for clinical practice. Journal of Psychology andChrisiianiiy, 16, 73-79.

Bjorck, J. P., Brown, J. A., cS Goodman, M. (2000).Casebook for managing managed care: A seif-siudyguide for ireaimeni planning, documeniaiion, andcommunicaiion. Washington, DC: American PsychiatricCorporation, Inc.

Breunlin, D. C. (1980). Multimodal behavioral treat-ment of a child's eliminative disturbance. Psychoihera-py: Theory, Research, and Practice, 7 7, 17-23.

Brunell, L. F. (1978). A multimodal treatment modelfor a mental hospital: Designing specific treatments forspecific problems. Professional Psychology, 9, 570-579.

150 MULTIMODAL THERAPY

Buckley, W. (1967). Modern systems research for ihebehavioral scieniisi. Chicago, IL: Aldine.

Fiala, W. E., Bjorck, J. P., & Gorsuch, R. L. (2002).The Religious Support Scale: Construction, validation,and cross-validation. American Journai of CommunityPsychology, 30, 761-786.

Herman, S. M. (1993). A demonstration of the validi-ty of the Multimodal Structural Profile Inventorythrough a correlation with the Vocational PreferenceInventory. Psychoiherapy in Privaie Practice, 11, 71-80.

Herman, S. M., and Roudebush, R. L. (1998). Therelationship between therapist-client modality similarityand psychotherapy outcomes. Journal of Psychoihera-py Practice and Research, 7, 56-64.

Janoff-Bulman, R. (1992). Shattered assumptions.New York, NY: The Free Press.

Keat, D. B. (1996). Multimodal therapy with chil-dren: Anxious Ashley. Psychoiherapy in Privaie Prac-tice, 15, 63-79.

bizarus, A. A. (1958). New methods in psychotherapy:A case study. South African Medical Journal, 32, 660-664

Lazarus, A. A. (1971). Behavior therapy and beyond.New York, NY: McGraw-Hill.

Lazarus, A. A. (1973). Multimodal behavior therapy:Treating the BASIC ID. Journal of Nervous and MentalDiseases, 156, 404-411.

Lazarus, A. A. (1976). Muliimodal behavior iherapy.New York, NY: Springer.

Lazarus, A. A. (1985). Casehook of muiiimodal ihera-py. New York, NY: Guilford Press..

Lazams, A. A. (1989). The practice of muitimodai iher-apy: Systematic, comprehensive, and effeciivepsychoiher-apy. Baltimore, MD: Johns Hopkins University Press.

Lazarus, A. A. (1996). The utility and futility of com-bining treatments in psychotherapy. Clinicai psychoio-gy: Science and practice, 3, 59-68.

Lazaraus, A. A. (2005). The case of 'Ben': A flexible,holistic application of multimodal therapy. PragmaiicCase Studies in Psychoiherapy, 1, 1-15.

Lazaais, A. A. (2006a). Brief but comprehensive psy-chotherapy: The muiiimodai way. New York, NY: Springer.

Lazaais, A. A. (2006b). Multimodal therapy: A seven-point integration. In G. Strieker & J. Gold (Eds.), Acasehook of psychoiherapy iniegraiion (pp. 17-28).Washington, DC: American Psychological Association.

Lazarus, A. A. (2007) Multimodal therapy. In R. J.Corsini, & D. Wedding (Eds.), Current psychoiherapies.(8th ed., pp. 337-371). Belmont, CA: Brooks Cole.

Lazaais, A. A., & Zur, O. (2002). Dual relaiionshipsand psychotherapy. New York, NY: Springer

Lazaais, R. S. (1991). Progress on a cognitive-moti-vational-relational theory of emotion. American Psy-chologisi, 46, 819-834.

Martin-Causey, T, & Hinkle, J. S. (1995). Multimodaltherapy with an aggressive preadolescent: A demon-stration of effectiveness and accountability. Journal ofCounseling and Developmeni, 73, 305-310.

Millon, T (1994). Millon clinical muliiaxial invento-ry-Ill Minneapolis: National Computer Systems, Inc.

Nelson-Jones, R. (2001). Theory and practice ofcounseling & iherapy. New York, NY: Continuum.

Nunnally, J. C, & Bernstein, I. H. (1994). Psychomei-ric iheory. New York: McGraw-Hill.

Richard, J. T. (1999). Multimodal therapy: A usefulmodel for the executive coach. Consuliing PsychoiogyJournai: Practice and Research, 51, 24-30.

Rogers, C. R. (1951). Ciient-centered therapy. Boston,MA: Houghton Mifflin Company.

Sue, D. W. & Sue, D. (1999). Counseling the cultur-ally differeni: Theory andpraciice (3rd ed.). New York:John Wiley & Sons.

Tan, S.-Y. (1991). Lay counseiing: EquippingChristians for a helping ministry. Grand Rapids, MI:Zondervan.

Tan, S.-Y. (1996). Religion in clinical practice: Implic-it and explicit integration. In E. Shafranske (Ed.), Reli-gion and the clinical practice of psychology (pp.365-387), Washington, DC: American PsychologicalAssociation.

Trice, P. D., & Bjorck, J. P. (2006). Pentecostal per-spectives on causes and cures of depression. Profes-sionai Psychoiogy: Research and Praciice, 37, 283-294.

Watzlawick, P., Weakland, J., & Fisch, R. (1974).Change: Principles of prohlem formaiion and problemresoluiion. New York, NY: Guilford Press.

Author

Jeff Bjorck received his PhD in clinical psychologyfrom the Universiiy of Oeiaivare and began as afacuiiymember ai Fuller Theologicai Seminary's GraduaieSchool of Psychology in 1990. Curreniiy, he is a professorof psychoiogy and a licensed psychoiogisi in privaie prac-.,iice. His research interests indude reiigious support andreiigious coping. Currentiy, he is focusing ihese inierestson both Christian adoiescents and on adults from vari-ous eihnocuiturai and faiih backgrounds. He serves asan elder ai his local church, where he also occasionaiiypreaches and ieaches.