Copyright 2007 Jeff Brooks-Harris 1 Multitheoretical Psychotherapy: A New Approach To Integrative...

Copyright 2007 Jeff Brooks-Harris www.multitheoretical.com

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Multitheoretical Psychotherapy:

A New Approach To Integrative Treatment

Jeff E. Brooks-Harris, Ph.D., ABPPUniversity of Hawaii at Manoa


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Making a Patchwork Quilt

Providing multitheoretical psychotherapy is like making a patchwork quilt. A counselor chooses individual pieces of cloth (strategies) from different types of fabric (theories) and assembles them in a unique pattern.

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Are you multitheoretical?

How many theories do you feel comfortable using to

conceptualize clients or guide interventions?


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Assimilative Integration

• Many integrative therapists choose a foundational theory but use ideas and strategies from other approaches as well.

• Assimilative Integration favors a firm grounding in a single system of psychotherapy and then incorporates techniques from different theories within the preferred orientation.


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Multitheoretical Psychotherapy• Multitheoretical Psychotherapy (MTP) provides a

way to understand the relationship between psychotherapy theories based on the way these approaches focus on different dimensions.

• MTP describes a catalog of key strategies that counselors can learn over time.

• MTP describes a method of integrative treatment planning based on collaborative dialogue with individual clients.


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Introduction to MTPFour Lessons

1. Five Principles for Integrative Psychotherapy

2. Working Interactively

3. Working Contextually

4. Integrative Treatment Planning


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LESSON ONE

Five Principles for

Integrative Psychotherapy


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Integrative psychotherapy should be…

• Intentional

• Multidimensional

• Multitheoretical

• Strategy-based

• Relational


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PRINCIPLE ONE

Intentional Integration• Psychotherapy should be based on intentional

choices• Intentionality should guide a therapist’s choice

of focus, conceptualization, and intervention strategies

• Intentionality supports idiographic treatment, allowing counselors to tailor therapy to the individual needs of each client


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Intentional integration represents a middle ground between intuitive and technical

integration

Intuitive INTENTIONAL Technical

Intuitive Integration Based on the therapists’ clinical wisdom and personal perceptions

Intentional Integration Based on collaborative dialogue with clients and is informed by clinical experience, theory, and research

Technical Integration Based on scientific research or treatment protocols written by experts


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PRINCIPLE TWO

Multidimensional Integration Psychotherapy should recognize the rich interaction

between multiple dimensions within individuals’ lives Integrative psychotherapy supports multidimensional

adaptation in the form of functional thoughts, effective actions, and adaptive feelings that allow clients to adjust to biological, interpersonal, systemic, and cultural contexts


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Cultural Contexts

Social Systems

Interpersonal Patterns

Biology

Thoughts Feelings

Actions

Multidimensional Model of Human Functioning


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PRINCIPLE THREE

Multitheoretical Integration• Integrative psychotherapists utilize diverse theories to

understand clients and guide interventions• Multitheoretical conceptualization allows therapists to view

theories as complementary vantage points to create a comprehensive formulation

• Multitheoretical practice involves combining strategies from different theoretical traditions

• Multitheoretical integration enacts a pluralistic philosophy, emphasizing diversity rather than homogeneity and multiplicity rather than unity


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Multitheoretical Framework for Psychotherapy

Theoretical Approaches Focal Dimensions

Cognitive Thoughts

Behavioral Actions

Experiential Feelings

Biopsychosocial Biology

Psychodynamic Interpersonal Patterns

Systemic Social Systems

Multicultural Cultural Contexts


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PRINCIPLE FOUR

Strategy-Based Integration

• Integrative psychotherapists utilize a wide variety of specific strategies drawn from different theoretical traditions

• Strategy-based integration enacts a pragmatic philosophy, translating theory into action

• Integration occurs when strategies from different theories are combined in practice

• Underlying theories do not need to be reconciled


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Key Strategies• Key strategies are skills or techniques that counselors

use with clients to work toward therapeutic goals• Strategy markers indicate when a particular strategy may

be useful• Expected consequences describe the likely outcome of

using a specific strategy• Key strategies can be learned, practiced, and

implemented with clients


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Cognitive Strategy 9.Encouraging accurate perceptions of

realistic constraints

• Strategy Marker: When clients are focusing on unrealistic hopes that interfere with effective problem solving, it is appropriate to encourage accurate perceptions & proactive choices

• Expected Consequence: If clients are encouraged to recognize realistic constraints, the predicted outcome is more accurate views, more effective responses, & more adaptive choices


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Experiential Strategy 3.Encouraging awareness and expression of

feelings

• Strategy Marker: When clients are unaware of their own feelings, or ignore and suppress them, you should encourage awareness and expression

• Expected Consequence: If awareness and expression of feelings is encouraged, it is anticipated that clients will gain insight from their emotions and consolidate their personal experiences


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PRINCIPLE FIVE

Relational Integration

• Psychotherapy integration should be implemented within the context of an effective therapeutic relationship.

• Different styles of relationships can be developed with clients based on individual needs and preferences.


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Relationship Styles Encouraged byDifferent Theoretical Approaches

Theoretical Approaches Relationship Styles

Cognitive Collaborative Empiricism

Behavioral Social Reinforcement

Experiential Empathic Attunement

Biopsychosocial Health Promotion

Psychodynamic Participant-Observation

Systemic Social Choreography

Multicultural Cultural Consultation


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LESSON TWO

Working Interactively with

Thoughts, Actions, & Feelings


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Maladaptive thoughts, actions, and feelings

are highly interactive

Dysfunctional Maladaptive

Thoughts Feelings

Ineffective

Actions


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Maladaptive Interactions

• Maladaptive Feelings like hopelessness are often associated with…

• Dysfunctional Thoughts like “I’m a loser; no one would want to date me,” and…

• Ineffective Actions like social isolation and withdrawal.


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Adaptive Interactions• Adaptive Feelings—like hope and a

desire to overcome loneliness—are more likely to be associated with…

• Functional Thoughts like “Maybe I’ll meet someone nice at the party,” and…

• Effective Actions associated with overcoming fears and talking to new people in a social setting.


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Working Interactively

• A counselor can work interactively with thoughts, actions, and feelings to promote multidimensional adaptation and change.

• Different points of clinical leverage can be used with different clients or in response to different situations with the same client.


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Cognitive Strategies

• Cognitive psychotherapy focuses on thoughts and uses these cognitions as a point of clinical leverage to encourage multidimensional change.

• Cognitive strategies encourage functional thoughts that are rational, evidence-based, and promote effective adaptation to the environment.


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Cognitive interventions are designed to have a primary impact on thoughts and a

secondary impact on actions and feelings

Cognitive Functional Adaptive

Strategies Thoughts Feelings

Effective

Actions


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Reflecting on Practice

What kinds of cognitive strategies do you use with clients to

encourage functional thoughts?


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Catalog of Key StrategiesCOG-1. Identifying ThoughtsCOG-2. Clarifying the Impact of ThoughtsCOG-3. Challenging Irrational ThoughtsCOG-4. Illuminating Core BeliefsCOG-5. Evaluating EvidenceCOG-6. Testing HypothesesCOG-7. Modifying BeliefsCOG-8. Reinforcing Adaptive Cognitions


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Catalog of Key Strategies

COG-9. Encouraging Accurate PerceptionsCOG-10. Supporting Dialectical ThinkingCOG-11. Fostering Mindful AwarenessCOG-12. Working with ImageryCOG-13. Brainstorming SolutionsCOG-14. Providing PsychoeducationCOG-15. Supporting Bibliotherapy


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Behavioral Strategies• Behavioral psychotherapy focuses on actions

and uses these behaviors as a point of clinical leverage to encourage multidimensional change.

• Behavioral strategies support effective actions or reduce maladaptive conditioned responses.

• Effective actions help people meet their needs, attain their goals, or avoid undesirable consequences.


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Behavioral interventions are designed to have a primary impact on actions and a

secondary impact on thoughts and feelings.

Behavioral Effective FunctionalStrategies Actions Thoughts

Adaptive

Feelings


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What kinds of behavioral strategies do you use with clients to support

effective actions?


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BHV-1. Clarifying Impact of Actions

BHV-2. Reinforcement & Conditioning

BHV-3. Identifying Target Actions

BHV-4. Determining Baselines

BHV-5. Encouraging Active Choices

BHV-6. Assessing Stages of Change

BHV-7. Schedules of Reinforcement


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Catalog of Key StrategiesBHV-8. Assigning Homework

BHV-9. Constructing a Hierarchy

BHV-10. Exposing Clients to Images or Experiences

BHV-11. Fostering Acceptance

BHV-12. Encouraging Commitments

BHV-13. Providing Training & Rehearsal

BHV-14. Coaching & Shaping


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Experiential Strategies• Experiential psychotherapy focuses on feelings

and uses these emotions as a point of clinical leverage to encourage multidimensional change.

• Experiential-Humanistic strategies encourage adaptive feelings, explore personal experiences, and promote awareness and growth.

• Adaptive feelings help people evaluate situations, organize for effective action, and match situations in a proportional manner.


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Experiential interventions are designed to have a primary impact on feelings and a

secondary impact on thoughts and actions.

Experiential Adaptive FunctionalStrategies Feelings Thoughts

Effective

Actions


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What kinds of experiential strategies do you use with clients

to explore adaptive feelings?


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EXP-1. Identifying Feelings

EXP-2. Clarifying the Impact of Feelings

EXP-3. Encouraging Expression of Feelings

EXP-4. Fostering Self-Actualization

EXP-5. Empathy & Positive Regard

EXP-6. Supporting Authenticity


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EXP-7. Integrating Parts of Self

EXP-8. Focusing Attention

EXP-9. Fostering Here-and-Now Awareness

EXP-10. Creating Experiments

EXP-11. Accepting Freedom & Responsibility

EXP-12. Recognizing Existential Limitations


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Reflecting on Concurrent Dimensions

• Do you focus more on clients’ thoughts, actions, or feelings?

• Which of these dimensions do you focus on the least?

• Would you like to learn more about any of these strategies?


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LESSON THREE

Exploring Biological, Interpersonal, Systemic, and

Cultural Contexts


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Where do maladaptive thoughts, actions,

and feelings come from? Dysfunctional thoughts, ineffective actions, and maladaptive feelings are shaped by…

• Biology

• Interpersonal Patterns

• Social Systems

• Cultural Contexts


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Working Contextually

An integrative psychotherapist explores and works within biological, interpersonal, systemic, and cultural contexts to promote adaptation to these environments


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Biopsychosocial Psychotherapy

• Biopsychosocial Psychotherapy focuses on biology, connecting body and brain.

• Biological approaches include health psychology, psychiatry, and body therapies.

• Biopsychosocial strategies encourage adaptive health practices that result in biological health, holistic wellness, and mind-body awareness.


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What do you do with clients to promote biological health, holistic

wellness, or mind-body awareness?


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Catalog of Key StrategiesBIO-1. Exploring the Effect of Biology on Psychological

FunctioningBIO-2. Recognizing the Influence of Psychological

Functioning on HealthBIO-3. Considering the Interaction between Health and

RelationshipsBIO-4. Understanding Health within a Sociocultural ContextBIO-5. Encouraging Physical WellnessBIO-6. Reducing Substance Use


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BIO-7. Teaching Relaxation

BIO-8. Fostering Physiological Awareness

BIO-9. Working Interactively with Body and Brain

BIO-10. Facilitating Acceptance of Illness

BIO-11. Encouraging an Active Role in Health Care

BIO-12. Considering Psychotropic Medication

BIO-13. Considering Alternative Interventions


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Psychodynamic-Interpersonal Strategies

• Psychodynamic-Interpersonal Psychotherapy focuses on interpersonal patterns and perceptions as well as unconscious processes.

• Psychodynamic strategies support adaptive interpersonal perceptions that are accurate and not distorted by past relationships and painful experiences.

• Interpersonal psychotherapy strategies encourage adaptive interpersonal skills that support relationships, help resolve conflicts, and facilitate role transitions.


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What do you do with clients to explore interpersonal patterns,

encourage clear perceptions, and promote effective relationships?


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Catalog of Key StrategiesPSY-1. Listening to Narratives

PSY-2 . Encouraging Free Association

PSY-3. Identifying Relationship Themes

PSY-4 . Making Interpersonal Interpretations

PSY-5. Honoring Resistance

PSY-6. Exploring Childhood Experiences

PSY-7 . Working Through Past Conflicts

PSY-8 . Identifying Attachment Styles


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PSY-9 . Observing the Therapeutic RelationshipPSY-10. Attending to Subjective ResponsesPSY-11. Resolving Conflicts in the Therapeutic RelationshipPSY-12. Modifying Relational InteractionsPSY-13. Interpreting DreamsPSY-14. Adapting to Interpersonal Losses or DisputesPSY-15. Encouraging New RelationshipsPSY-16. Learning from Termination


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Systemic-Constructivist Strategies

• Systemic-Constructivist Psychotherapy focuses on family systems, social groups, and personal narratives.

• Systemic strategies encourage adaptive social practices that allow individual growth and individuation without threatening the stability of the family system.

• Constructivist strategies encourage adaptive personal narratives that construct meaning in a way that matches a person’s experience and supports positive action.


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What do you do to explore clients’ family and social systems and help them construct meaning in an

adaptive manner?


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Catalog of Key StrategiesSYS-1. Understanding Problems w/in Social Context

SYS-2. Viewing Families as Systems

SYS-3. Detecting Repetitive Interaction Patterns

SYS-4. Describing the Structure of the Family

SYS-5. Identifying Family Roles

SYS-6. Searching for Multigenerational Patterns

SYS-7. Clarifying Family Belief Systems


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Catalog of Key Strategies• SYS-8. Giving Directives for Strategic Change• SYS-9. Exploring Social Construction of Meaning• SYS-10. Externalizing Problems• SYS-11. Encouraging Adaptive Narratives• SYS-12. Utilizing Clients’ Resources • SYS-13. Constructing Solutions• SYS-14. Orienting Toward the Future


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Multicultural-Feminist Strategies

• Multicultural-Feminist Psychotherapy focuses on culture, identity, gender, and power.

• Multicultural strategies encourage adaptive cultural practices and values.

• Adaptive cultural practices allow people to adjust to cultural contexts without violating values.

• Adaptive cultural values allow individuals to appreciate their own group as well as respecting others.


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What do you do to understand cultural identity and values or support cultural adaptation?


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Catalog of Key StrategiesMCUL-1. Viewing Clients Culturally

MCUL-2. Clarifying the Impact of Culture

MCUL-3. Creating Culturally-Appropriate Relationships

MCUL-4. Celebrating Diversity

MCUL-5. Illuminating Similarities & Differences

MCUL-6. Recognizing the Impact of Identity

MCUL-7. Facilitating Identity Development


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MCUL-8. Appreciating Multiple IdentitiesMCUL-9. Highlighting Oppression & PrivilegeMCUL-10. Exploring Societal ExpectationsMCUL-11. Supporting Social ActionMCUL-12. Integrating Spiritual AwarenessMCUL-13. Becoming Aware of Therapist’s

WorldviewMCUL-14. Reducing Cultural Biases


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Reflecting on Contextual Dimensions

• Which contextual dimensions do you focus on the most with clients: Biology, Interpersonal, Systems, or Culture?

• Which context do you focus on least?

• Would you like to learn more about any of these strategies?


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LESSON FOUR

Integrative Treatment Planning


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Customizing Treatment

• “The therapist must strive to create a new therapy for each patient.” (Yalom, 2002, p. 34)

• Integrative treatment planning provides a practical method for customizing psychotherapy to the needs of an individual client.


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Where to Focus?

• It is not practical or helpful to focus on several dimensions at once

• You may want to start by focusing on two or three salient dimensions closely related to the problem

• It may be helpful to look at the interaction between a concurrent (TAF) and a contextual (BISC) dimension

• Treatment planning can be used to select a focus that will guide conceptualization and interventions


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Integrative Treatment Planning

1. Conducting a Multidimensional Survey 2. Establishing an Interactive Focus on

2 or 3 Dimensions3. Formulating a Multitheoretical

Conceptualization4. Choosing Interventions from a Catalog of

Key Strategies


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Case Example: MTP for Depression

• Claire is a Japanese-American female in her 50’s• Experiencing symptoms of depression since the

death of her mother just over a year ago• Oldest of three daughters and never married• Claire lived with her mother and was the primary

caretaker while her mother was dying


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1. Conducting a Multidimensional Survey

• After clients have had a chance to describe their concerns, you can explore concurrent dimensions: (1) thoughts, (2) actions, &

(3) feelings.• As well as contextual dimensions:

(4) biology, (5) interpersonal patterns,

(6) social systems, & (7) cultural contexts.


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Claire’s Multidimensional Survey:Concurrent Dimensions

Thoughts: “I can’t go on without my mother.”

Actions: Social isolation from family and friends.

Feelings: Despair, hopelessness, and emptiness.

When asked about feelings of sadness, Claire reported a numb sense of distance from any sadness


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Claire’s Multidimensional Survey:Contextual Dimensions

Biology: Decreased appetite and troubled sleeping.

Interpersonal: Claire had tried to be her mother’s favorite since childhood.


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Claire’s Multidimensional Survey:Contextual Dimensions

Social: As a child, Claire competed with her sisters for her mother’s attention. Her father was a good provider but was emotionally distant. Her father died ten years ago. Her sisters are both married with children of their own.

Cultural: As the eldest daughter in a Japanese-American family, Claire felt an obligation to take care of her parents.


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2. Establishing an Interactive Focus

• After surveying all seven dimensions, choose two or three which will serve as the initial focus for psychotherapy

• The choice of focal dimensions should be based on collaborative dialogue

• Ask the client to begin to monitor the interaction between two focal dimensions


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Claire’s Interactive Focus

• After exploring all seven dimensions, Dr. P. and Claire decided to focus on the interaction between feelings and interpersonal patterns.

• Feelings – Hopelessness and despair.

• Interpersonal Patterns – Claire’s close relationship with her mother may have kept her from developing other sources of social support.


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3. Formulating a Multitheoretical Conceptualization

• For each focal dimension, use a model of conceptualization from a corresponding theory:

(e.g., feelings experiential model,

interpersonal psychodynamic, etc.)• Formulate initial conceptual hypotheses.• Expand your conceptualization with more

information.


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Experiential Conceptualizationfor Claire

Emotion Focused Therapy• Claire’s feelings of hopelessness (“I can’t go on”)

may be interfering with a healthy grieving process• Adaptive Primary Emotion: Sadness• Secondary Emotion: Hopelessness• Recommendation: Help Claire explore and

express her sadness in adaptive ways


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Psychodynamic Conceptualizationfor Claire

Core Conflictual Relationship Theme:• Wish: Claire wanted to be her mother’s favorite.• Response of Other: Claire’s mother maintained a

close bond through strict control.• Response of Self: Claire was dedicated to making

her mother happy and gave up her own goals. Claire cherished the close bond but, later, resented her mother’s control over her life.


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4. Choosing Interventions from aCatalog of Key Strategies

• Emphasize the use of intervention strategies from theories that address focal dimensions:

(e.g., feelings experiential strategies

interpersonal psychodynamic, etc.)• Interventions from seven theoretical traditions

are described in the Catalog of Key Strategies.


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Key Strategies used with ClaireExperiential-Humanistic Strategies

EXP-2. Clarifying the Impact of Feelings

EXP-3. Encouraging Expression of Feelings

EXP-6. Supporting Authenticity

Psychodynamic-Interpersonal Strategies

PSY-3. Identifying Relationship Themes

PSY-4. Exploring Childhood Experiences

PSY-14. Adapting to Interpersonal Losses


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Demonstration ofIntegrative Treatment Planning

1. Conducting a Multidimensional Survey

2. Establishing an Interactive Focus on 2 or 3 Dimensions

3. Formulating a Multitheoretical Conceptualization

4. Choosing Interventions from a Catalog of Key Strategies


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Discussion / Action Plan

• Based on what you learned today, are there ideas you would like to apply to your work?

• What can you do to start thinking and working with clients in a more multitheoretical manner?

• If you provide training or supervision, are there ideas or concepts from MTP you would like to use in training?


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Integrative Multitheoretical Psychotherapy

Jeff E. Brooks-Harris (2008)

Boston: Houghton Mifflin

http://www.college.hmco.com/CollegeCatalog/CatalogController?cmd=Portal&subcmd=display&ProductID=14303


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Training Videos

Available from Microtraining Associates:

Cognitive

Behavioral

Experiential

Psychodynamic

Multicultural

www.emicrotraining.com


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Contact Information

Jeff E. Brooks-Harris, Ph.D.

University of Hawaii at Manoa

[email protected]

(808) 956-7927

website:

www.multitheoretical.com

Copyright 2007 Jeff Brooks-Harris 1 Multitheoretical Psychotherapy: A New Approach To Integrative...

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