KKT 60103 TEORI KAUNSELING LANJUTAN (M222)

SEMESTER 2 SESI 2022/2023

MULTIMODAL THERAPY THEORY

NO. FULL NAME MATRIC NUUMBER

1 KOUSALYA A/P SIVAKUMARAN M20222002158
 About Founder

Arnold A. Lazarus was a well-known clinical psychologist who is revolutionized the

field of psychotherapy through his groundbreaking contributions and innovative approaches.
He born on 26th January 1932 in Johannesburg, South Africa and immigrated to United states
in 1947. Throughout his life, Lazarus developed and refined a various therapeutic technique
such as behaviour therapy and cognitive-behaviour therapy and then these leads to the creation
of his multi-dimensional psychotherapy which is Multimodal Therapy.

Lazarus completed both his undergraduate and postgraduate studies at the University
of Witwatersrand in Johannesburg. In 1956 he earned his B.A. with honours, in 1957 he
completed his M.A. and in 1960 he received doctorate in clinical psychology. This was the time
Lazarus started to focus on behavioural psychology and developed his therapy based on this
approach. Over time, Lazarus expanded his focus and incorporated with cognitive elements
which leads him to develop therapy based on cognitive behavioural therapy. However, Lazarus
realized that just focusing on one aspect such as solely on behavioural or cognitive was too
limited for effective psychotherapy. In 1958, while he was student, he published a seminal
paper in South Africa Medical Journal introducing his new therapy based on behaviour therapy.
This early work marked the initial step in Lazarus’s trajectory as a pioneer in psychotherapy.
In 1959, after the publication, he commenced his private practice in psychotherapy in
Johannesburg. Through this, he gained valuable clinical experience and expertized his
therapeutic skills.

In 1963, he was invited to serve as a visiting assistant professor of psychology at

Stanford University in United States which was a new turn in Lazarus’s journey. His visit as an
assistant professor, opened doors for Lazarus to further expand his horizons and to collaborate
with distinguished scholars in the field. After his tenure at Stanford, Lazarus returned to the
University of Witwatersrand as a lecturer in psychiatry at the school of medical where he also
continued to make strides in his research and clinical practice. In 1966, Lazarus accepted a
position as the director of Behavioural Therapy Institute in Sausalito, California. During this
time, he also published ‘Behaviour Therapy Techniques’ with Josep Wolpe, which solidified
his status as a respected authority in the field.

Then, in the following year, Lazarus’s career flourished as become a professor of

behavioural science at Temple University Medical School in Philadelphia whereas in 1970 he
served as a visiting professor of psychology and director of clinical training at Yale University.
In group therapy settings, Lazarus was the first psychologist to utilize desensitisation
techniques for the treatment of phobias. This shows that Lazarus’s contribution to
psychotherapy were not closed to theoretical aspect but also a visionary in the realm of clinical
application. In 1960s, Lazarus found that his therapy had limitations where it centred primarily
on behaviourist principles. Therefore, he came up with a more comprehensive approach which
was necessary for effective psychotherapy. Then, this realization leads him to publish a book
titled ‘Behavioural Therapy and Beyond’ in 1971. He integrated behavioural techniques with
cognitive process which proved to be a significant advancement in psychotherapeutic practice,
providing a more holistic approach to human development and psychology.

The usage of CBT in treating patients with anxiety disorders, depression, and other
difficulties, provided improvement in several areas however, in long run Lazarus noticed that
the rate of relapse in those patients are high. From here, Lazarus understood that barely
focusing on just two aspects of human development such behaviour and cognitive is inadequate
for solving clients’ problems. Therefore, to address these shortcomings, he conceptualized a
therapy called Multimodal therapy. This is a comprehensive approach which encompasses
seven interrelated modalities such as behaviour, affect, sensation, imagery, cognitive,
interpersonal relationships, and drugs or biological (Kibuthu, 2020). His invaluable
contribution to the field were recognized and so he was elected as a diplomate of International
Academy of Behavioural Medicine, Counselling, and Psychotherapy and became a fellow of
the American Psychological Association (APA) in 1972.

In 1976, Multimodal Therapy Institute was established by Lazarus in Kingston, New

Jersey which was run under his guidance. Other than this, he also established additional
institutes in various states across the United States. Lazarus also provided care and support to
numerous clients, spanning individuals, couples, families, and groups using MMT. Then, he
also made important contributions to the academic community where he served as a professor
and chairman of the psychology department at Rutgers University in New Brunswick, New
Jersey. Lazarus actively participated in the boards of influential psychology journals and held
positions in respected organizations such as Psychologists for Social Responsibility.

Throughout Lazarus life and his career journey, he authored and edited almost 15 books
along with 200 articles and book chapters. He also collaborated with his son, psychologist
Clifford Neil Lazarus, to publish several well-known psychology books which inspires and
empowers the readers. His outstanding contribution was valued and noticed so that he was
awarded with numerous accolades and honours throughout his career. The American
Psychological Association bestowed upon him the Distinguished Psychologist Award,
Distinguished Professional Contributions Award, and Distinguished Service Award,
recognizing his exceptional achievements and impact on the field. Furthermore, he was
honoured with the Distinguished Career Award from the American Board of Medical
Psychotherapists and became a fellow of the Academy of Clinical Psychology.

Then he was retired as a Professor Emeritus from Rutgers University’s Graduate School
of Applied and Professional Psychology. In 2013, he passed away. His multimodal therapy
approach remained as a cornerstone of contemporary therapeutic practices till this day. His
contribution to the field of psychology and counselling served the other professionals as a
guideline to shape individuals who are seeking healing and transformation. According to
Lazarus, therapy is education rather than healing; it is growth rather than treatment. This shows
that Multimodal therapy is an educational based therapy which we will see in detail in the
subsequent part.
 Introduction

Multimodal therapy is psychotherapeutic approach that integrates both behavioural and

cognitive aspects of human functioning. It encompasses seven modalities such as Behaviour,
Affect, Sensation, Imagery, Cognition, Interpersonal relationships, and Drugs or Biological
(Sumari, Tharbe, et al., 2015). Multimodal takes a holistic approach to understand and treat
psychological difficulties in human beings by addressing all these seven modalities.

Each modality focuses on different aspects of human functioning however, each of the
modalities are interrelated with each other. This is because each individual is different from
each other and all of us are unique on our own way thus, using a same set of techniques to
address issues faced by every client seemed to be illogical and incompatible according to
Lazarus. In an interview, Lazarus expressed that multimodal therapy is not limited to focusing
on a single aspect. Instead, it incorporates multiple techniques to assess the suitability of each
approach for an individual. This assessment takes into consideration the client's values, beliefs,
and cognition to ensure alignment with their unique needs and preferences. By utilizing a range
of techniques, multimodal therapy aims to provide a comprehensive and tailored approach to
therapy that addresses the diverse aspects of an individual's experience.

Therefore, in Multimodal therapy these seven modalities were used. Behaviour focuses
on observable actions and responses of individuals, while Affect emphasized emotions, moods
and other strong feelings which influences a person's mental well-being (Suraeni & Kustyarini,
2019). Sensation refers to all bodily physiological responses through five senses such as touch,
smell, taste, hear and vision, whereas imagery involves individual description about themselves
such memories and fantasies (Suraeni & Kustyarini, 2019). Cognition examines thoughts,
beliefs, and cognitive processes, and Interpersonal relationships focuses on social connections
and their impact on psychological health. Lastly, Drugs/Biology considers the influence of
substances and biological factors on mental functioning.

By considering all seven modalities, multimodal therapy aims to provide assessment

and personalized treatment approach. There are several basic assumptions of this theory which
we would be exploring in next section.
 Fundamental Concept of Multimodal Therapy

There are several fundamental concepts of Multimodal Therapy (MMT) which should
be understood by each counsellor before utilising it into their counselling sessions.
Fundamental concept means the basic assumption or the overview of the whole theory.
Multimodal therapy is a therapy that emphasizes on personal and individualized approach into
intervention. This basically means from multimodal viewpoint; every individual is unique and
different from each other. Each individual has their own set of needs, values and beliefs.
Therefore, MMT encourages to adapt the therapy techniques based on the specific needs of the
clients, ensuring that the approach aligns with their preferences and expectations (Ojo, 2010).
From this aspect there are several fundamental concepts.

Firstly, MMT assumes that personality is a combination of a series of factors such as

genetic, physical environment and social learning history. This shows that MMT sees
personality in holistic view where individuals’ personality is shaped by a complex interplay of
various factors. Other than that, MMT acknowledges that an individual does not react to the
environment or an event solely rather their reactions are based on their perception of the
environment. This basically means that environment is not a direct contribution to a person's
behaviour whereas how they see that particular environment or event is what plays a major role
in producing certain behaviour or action of theirs (Sumari, Tharbe, et al., 2015). This
perspective highlights the importance of exploring an individual's cognitive processes and
beliefs to understand their emotional and behavioural responses.

Then, according to multimodal therapy, every individual is regarded as equal regardless

of their social status or role in life. This theory also emphasized that there is no individual is
inherently superior to another. For example, if one person has proficiency in a particular area
does not make an individual superior to others who may not possess the same skills or
knowledge. Talent in a specific aspect should not be seen as a measure of overall worth or
superiority. This is said so because each person possesses unique strengths and resources
(Sumari, Tharbe, et al., 2015). Just because someone excels in one field does not diminish the
value or worth of others who may have different talents or interests.

Furthermore, multimodal therapy also includes elements from Cognitive Behavioural

Therapy (CBT) and Rational Emotive Therapy (RET). There are few fundamental concepts
shared from these theories as well. For instance, MMT recognizes that people’s problems
emerge from inadequate learning or mistakes in learning. By addressing these underlying
issues, MMT aims to bring positive changes in clients. In multimodal therapy, counsellor and
client relationship is seen as coach and trainee (Sumari, Tharbe, et al., 2015). In simpler words,
we can say that in MMT, counsellor plays the role as a teacher and client plays the role as a
student since this therapy is education-based approach where educating the client regarding the
issues they are facing is the crucial part of interventions. The counsellor also assumes a role of
guidance and skill-building, where he or she assists client in acquiring and applying new coping
strategies (Martin-Causey & Hinkle, 1995), and problem-solving techniques.

Another fundamental concept of multimodal therapy is that applying therapy to real-

life situation is not automatic. Instead, clients are given assignments and tasks that enable them
to practice and generalize their newfound skills in everyday life. Besides, diagnostic labels are
used in MMT to identify and describe specific behavioural patterns (Sumari, Tharbe, et al.,
2015). Diagnostic labels typically refer to the seven modalities which are BASIC ID.
Diagnostic labels are used in this therapy because they provide a framework for therapists to
track changes in client’s behaviour, monitor progress, and facilitate communication and
collaboration among client and counsellor.

Lazarus believed that visualizing a person's belief system using BASIC ID framework,
is crucial for positive change. When client can visualize their belief system through these 7
modalities, they will be more prone to respond positively to their world. They will be able to
recognise the aspects that need to be improvised and will start to work on it. Therefore, as a
counsellor who practices Multimodal therapy in their counselling setting must be expertise in
comprehending the meaning and elements of BASIC ID as this:

• B - Behaviour: Examining the client's behavioural patterns and identifying maladaptive

behaviours to address.
• A - Affect: Exploring the client's emotions and helping them manage and express their
feelings effectively.
• S - Sensation: Focusing on bodily sensations and physical experiences to address any
somatic symptoms or discomfort.
• I - Imagery: Exploring the client's mental imagery.
• C - Cognition: Identifying and challenging cognitive distortions or negative thought
patterns that contribute to the client's difficulties.
 • I - Interpersonal Relationships: Exploring the client's relationships with others and
addressing any issues related to communication, boundaries, or conflict resolution.
• D - Drugs/Biology: Considering any biological or physiological factors that may be
influencing the client's psychological well-being, such as medication or physical health
conditions.

From my point of view, understanding the fundamental concepts of multimodal therapy

is very important for counsellors when utilizing this approach in their counselling session. This
is said so because MMT is unlike other therapy which just focuses on one particular aspect of
human psychology whereas it needs holistic understanding of various aspects of human
functions such as behaviour, affect, sensation, imagery, cognition, interpersonal relationship
and drugs or behaviour. By understanding this, counsellors could gain a comprehensive
understanding of clients' problems and can address in a wide range of client's concern. Besides,
by understanding those concepts, counsellors can tailor their treatment plans and interventions
to the specific needs and preferences of each client. This would bring great sense of
commitment and comfortability in clients to engage in all counselling sessions. Then, a solid
understanding of the fundamental concepts of MMT allows counsellors to establish a strong
therapeutic relationship with their clients. By demonstrating an understanding of the client's
unique experiences, employing appropriate techniques, and providing a safe and non-
judgmental space, counsellors can foster trust and rapport in client. Therefore, as a counsellor
we should be expertise in understanding these key concepts of Multimodal therapy.

In conclusion, MMT emphasizes a personal and individualized approach, recognizing

the uniqueness of each individual and adapting techniques to their specific needs. MMT
acknowledges the complex interplay of genetic, environmental, and social factors in shaping a
person’s personality. MMT also proposed that a person’s action is not based on the
environment, but it is more to the person’s perception of the reality. It promotes equality,
harnesses unique strengths, and emphasizes the visualization of belief systems for positive
change. MMT incorporates elements from CBT and RET, addresses learning-related issues,
and fosters a coach-trainee relationship. The application of therapy to real-life situations is
facilitated through assignments and tasks, while diagnostic labels aid in tracking progress and
guiding treatment.
 Counselling Process and Application Of MMT

Objectives of Multimodal Therapy

The objectives of Multimodal Therapy (MMT) revolve around tailoring the therapeutic
approach to meet the individual needs of each client, promoting efficient and effective change,
and fostering the client's personal growth and development.

One of the objectives of MMT is to avoid using one-size-fits-all approach and instead
focus on identifying the most suitable and effective therapeutic methods for each client. MMT
acknowledges that each individual has unique experiences, strength and challenges thus
imposing a standardized treatment method on all clients would not make expected changes in
client’s life. Customizing each therapeutic techniques based on client’s specific needs,
preferences and values will increase the effectiveness and relevance of the therapeutic
interventions (Ojo, 2010). This approach found that what works for one person might work for
another, hence a tailored treatment plan is essential for optimal outcomes (Zilbergeld, 1982).

The other objective of MMT is to assist clients in implementing desired changes as fast
as possible (Sumari, Tharbe, et al., 2015). All therapy’s ultimate goal would be to help clients
to achieve their targeted goals or expected change as soon as possible however, since MMT is
focused on all 7 dimensions, it might be taking quite sometimes to see the changes.
Nevertheless, by also utilizing a range of techniques and modalities, this approach might also
enable clients to address their concerns from multiple angles which can also accelerate the
process of therapy and facilitate positive changes.

The last but not least, Multimodal therapy aims to support clients in reducing their
psychological distress by promoting their self-growth and development. Throughout the
therapy, clients are encouraging to explore their strengths, build resilience and achieve personal
growth, which leads to a more fulfilling and meaningful life (Fall & Hodder, 2003).

Roles Of a Multimodal Therapy Counsellor

Counsellors hold several roles or responsibilities in order to accelerate the therapeutic

process of Multimodal Therapy (MMT). Firstly, counsellors should be actively engaged and
fully participated in the therapy sessions to create a collaborative and supportive environment
(Ojo, 2010). Counsellors should not just be a passive listener instead should act as a teacher
who assists the client to look through all aspects in order to address the issues from all crucial
dimensions. Secondly, counsellors should demonstrate flexibility and adaptability in managing
clients and their unique problems effectively. The main focus of Multimodal therapy is to
identify the suitable techniques for each client instead of forcing clients to take upon one
therapeutic approach. Therefore, as a counsellor we should have the tendency to look in broader
view rather than sticking to our own perception. As a counsellor, we should know how to adapt
or suit ourselves with each client as each case is different from others. Without flexibility and
adaptability in counsellors, multimodal therapy would not contribute to any positive changes
in the long run of the counselling sessions.

Thirdly, in multimodal therapy approach, a counsellor should not only act as a

counsellor or therapist in treating the clients whereas they should take on various roles such as
consultant, educator, coach and role model for the client. They provide guidance, offer insights
and knowledge to help clients gain a deeper understanding of their challenges and potential
solutions. Fourthly, as a multimodal counsellor, he or she should employ a range of techniques
and therapeutic styles. They assess the client’s individual style, personalities and needs so then
counsellors adapt their approach accordingly. This flexibility allows the counsellor to utilize
various modalities and interventions from MMT to address the client's specific issues
comprehensively (Sumari, Tharbe, et al., 2015).

Fifthly, one of the most important roles of a multimodal therapy counsellor is to identify
and address the key issues faced by clients across the BASIC ID modalities in collaboration
with the client (Sumari, Tharbe, et al., 2015). The client and counsellor work together to explore
different modalities and discuss the areas where the client is facing difficulties. They address
each of these areas and aim to find a comprehensive solution. Furthermore, counsellor’s
responsibility is to adapt their interpersonal style to suit the client during therapy session. For
example, a counsellor can adjust their communication and interaction style according to client’s
unique characteristic while conducting a therapy session. This does not mean that a counsellor
should act fake or unreal while being in session, instead they should make themselves familiar
with changes so that the counsellor can have a good connection with the client as well as can
relate to the client’s issues in order to produce an effective session.

In conclusion, in the counselling process of MMT, the counsellor plays multiple roles
and utilizes various techniques and styles to support the client throughout their therapeutic
journey. Through active engagement, flexibility, collaboration, and adaptability, the counsellor
works together with the client to address their issues across the different modalities, creating
positive change and promoting the client's well-being.

Counselling Process of MMT

As what mentioned, multimodal therapy emphasizes on the uniqueness of each

individual so, there is no standardized treatment approach used for all clients. One of the first
steps in the counselling process is to understand and prioritize the client's desires and goals for
therapy. The counsellor actively listens to the client's concerns and aspirations, ensuring that
their needs and preferences guide the therapeutic process. This collaborative approach
empowers the client and fosters a sense of ownership and engagement in their own healing
journey. Then, the counsellor and client delve deep into the client’s problems and challenges
by utilizing different perspective through the BASIC ID framework. To gain a better
understanding of the multimodal therapy (MMT) process, it is helpful to break it down into
eight important steps. However, before delving into these steps, it's essential to grasp the six
distinctive characteristics that set MMT apart from other therapies. These characteristics serve
as guidelines for the MMT process and provide counsellors with a clear understanding of what
makes MMT unique. Therefore, it is crucial for counsellors to familiarize themselves with these
characteristics, as they play a significant role in shaping the overall MMT approach.

Firstly, MMT has specific and comprehensive focus on the BASIC IB modalities. When
we look at other therapies, we do not see any that specifically target all seven aspects of how
humans’ function. It is quite challenging to address all these different areas comprehensively.
That is why MMT stands out with its own uniqueness in this regard. Secondly, it uses the
second-order BASIC ID sequence. In some cases, when the therapy process reaches a point
where progress seems to be stuck, a deeper exploration of various aspects can provide valuable
insights (Norcross & Goldfried, n.d.). This is called as the second-order BASIC ID. To make
long story short, second-order BASIC ID will be used by the counsellor when most obvious
techniques are not helpful (Ojo, 2010). They will start to reassess the initial techniques used
and then come up with new helpful and effective treatment after exploring deep the second
time.

Thirdly, the use of modality profile also makes MMT seems unique than other therapy
(Sumari, Tharbe, et al., 2015). The modality profile of a client encompasses all 7 modalities of
MMT where after the first session of counselling, counsellor will address client’s issues based
on these aspects and he or she will make a visualisation using BASIC ID. This will be explained
later with examples so that we can have the insight. Besides, firing order is also important in
MMT, referring to the sequential activation of modalities in response to triggers or stimuli. For
example, not all modalities are troublesome for a client, whereas they might only face
difficulties in certain aspects therefore, counsellor will address those aspects and arrange it
from the most important modality that need to be addressed and to the least important.

Fifthly, the bridging process is also one of the important elements that distinguishes
MMT from other therapy. In bridging process, the therapist tunes into the client's preferred way
of thinking (Sumari, Tharbe, et al., 2015). Let's imagine a situation where a therapist wants to
explore a client's emotional responses to an event, but the client responds with defensive and
irrelevant thoughts or speech instead of discussing their feelings. Confronting the client may
not be helpful, so bridging is often used where the counsellor focusses on the cognitive domain
first as the client prefers to discuss about it more than other aspects. Then, gradually counsellor
can dive into other prioritized domains. Lastly, the counsellor tracks the firing order throughout
therapy to detect any shifts or changes in the client’s prioritized modalities order. For example,
the firing order in the second session might not remain the same in the sixth session, so to
ensure that both counsellor and client are focusing on the right modality, it important to do the
tracking of firing order.

These are the 6 characteristics that makes MMT to be unique than any other therapies.
When it comes to the MMT process itself, it can be said as consisting of eight fundamental
steps. However, it is important to note that MMT is a flexible approach that recognizes the
individuality of each client. Thus, these eight steps are not rigidly standardized, but rather serve
as a general framework that can be adjusted and adapted to meet the specific needs and
preferences of each client. Counsellors play a crucial role in implementing these eight steps
within the MMT process. They are skilled educators who actively engage and collaborate with
clients throughout therapy. While MMT follows a systematic counselling process, it allows
room for counsellors to have the freedom to mix and match the steps based on their clients'
unique circumstances and therapeutic goals. Even in an interview, Lazarus mentioned that these
processes are not preset, whereas he can first use the Multimodal Life History Inventory first,
even before conducting the counselling session. This shows that these processes are not pre-
arranged, but it is just a framework of how MMT progresses in counselling setting.
 The therapy starts by allowing the client to openly discuss the issues they are facing
and everything they are going through. In this first step, counsellor and client talk about the
issues the client is facing in a comfortable environment of counselling setting. The counsellor
will first try to get information from clients verbally. In this part, they might use techniques
from other approaches to form their question structures. Then, after the conversation or first
counselling session, client will be provided with the Multimodal Life History Inventory
(Lazarus 1991). This is considered as the second step. Through that inventory, the counsellor
will be able to gain insight on client’s personal and social history, the description of client's
presenting problem, their expectations regarding therapy and also the analysis of modalities of
current problems.

During the third step of the Multimodal Therapy (MMT) process, after gathering
valuable information from the client's verbal expressions and the inventory assessment,
counsellor will be able to construct a comprehensive BASIC ID modalities profile. This profile
serves as a snapshot of the client's functioning across various modalities, including behaviour,
affect, sensation, imagery, cognition, interpersonal relationships, and the influence of drugs or
biological factors. To create the BASIC ID modalities profile, the counsellor carefully aligns
the information provided by the client during therapy sessions with the results obtained from
the assessment inventory. By integrating these two sources of information, the counsellor gains
a deeper understanding of the client's unique experiences, challenges, and strengths within each
modality. With the modalities profile in hand, the counsellor can then address the specific issues
and concerns the client is facing in each modality.

In fourth step, firing order will take place. After considering all the modalities,
counsellor and client will collaborate to arrange the modality in the order of priority where they
focus on the modalities that are most relevant and important to be treated first. For example, if
a client is struggling with anxiety and relationship issues, they may prioritize affect and
interpersonal relationships as the initial focus rather than behaviour and all other aspects. By
collaboratively identifying and prioritizing the most significant modalities, the counsellor can
tailor the therapeutic process to target the areas that require immediate attention and come up
with the most effective treatment plan.

Then occurs bridging procedure. Bridging procedure is not compulsory or necessary in

all cases but it is only applicable when the client does not give commitment to address the
targeted domain instead, they focus on other domain. An example of the bridging process in
Multimodal Therapy (MMT) can be seen in situations where a psychotherapist aims to address
a client's emotional responses, but the client seems to primarily focus on the cognitive domain.
In such cases, as described in the handbook of psychotherapy integration by Norcross and
Goldfried (n.d.), the therapist would initially engage with the client and explore the cognitive
domain, acknowledging the client's preferred modality. Through active listening and
discussion, the therapist would delve into the client's cognitive content, encouraging the client
to express their thoughts, beliefs, and judgments. During this exploration, the therapist may
gradually introduce questions related to the client's emotional experiences for instance, ‘How
do you feel when you think that you could not finish your task on time?’. By bridging from
the cognitive to the affect domain, the therapist gradually makes the client to reflect on their
underlying feelings and emotions, creating an opportunity for the client to open up and share
more intimately.

Then after creating the firing order and done with bridging process (if applicable), the
counsellor uses various combined therapy techniques from different approaches (Martin-
Causey & Hinkle, 1995a). Then they would create effective interventions based on BASIC ID.
In MMT, there is no rigid set of techniques that must be used and followed in treating clients
whereas, they take several techniques from other therapy and implement it in MMT based on
each modality. For example, let's say a counsellor wants to help a client overcome negative
thinking patterns. In this case, the counsellor may take a technique called cognitive
restructuring, which is used in cognitive behavioural therapy. Cognitive restructuring involves
identifying negative thoughts and replacing them with positive ones. So, the counsellor would
work with the client to challenge and change their negative thoughts, helping them develop
more positive thinking patterns. This demonstrates how counsellors in Multimodal Therapy
(MMT) incorporate techniques from other therapeutic approaches to address and solve
problems according to the client's specific BASIC ID modalities.

Next step is tracking. Firing order is periodically reassessed during sessions to

determine if the focused modalities have changed or remained the same. As what mentioned
before, the firing order might not remain the same as what it was in first session. Therefore, it
is crucial for counsellors to know in what modalities they should be focusing as the counselling
session goes on. Finally, at the end of the process or session, the counsellor assesses the client's
progress and identifies whether they have achieved positive changes using the BASIC ID
approach again. These is how MMT works in counselling setting by primarily emphasizing on
the usage of seven essential elements, BASIC ID. As a counsellor, we should also understand
that each modality is not an isolated or individual element whereas it is interrelated with other
(Lazarus, 1973). By understanding this, the counsellor can see the antecedent of the behaviour
and where to start the therapy at. The modalities are related with each other as bellow;

This is how each modality are connected and influenced by each other. For example, when a
person has chronic pain from an injury (sensation), he might have negative beliefs of himself.
He might believe he will never heal or that his condition might worsen to a life-threatening
extent (cognition). These negative thoughts can then have an impact on the person's emotions,
leading him to feel anger towards himself, depression, increased stress, and fear about his future
(affect). Then this might impact his imagination where he might imagine or visualize that he
could not walk again or function as before again in daily life (imagery). Consequently, these
negative thoughts, emotions, and images can further shape the person's behaviour, potentially
causing them to display anger or disappointment towards others and affecting their
interpersonal relationships. This example demonstrates how each modality in MMT is
interconnected and can have a cascading effect on the others.
 Example of Case Using Multimodal Therapy

Overview

Sarah is a 35-year-old woman struggling with avoiding social situations and cancelling plans,
finding it increasingly difficult to navigate social interactions. She revealed that intense anxiety
and fear were the driving forces behind her avoidance. The mere thought of being around
people triggered overwhelming emotions, and she constantly worried about being judged or
embarrassing herself. Sarah described the physical sensations that accompanied her anxiety,
such as a racing heart, sweaty palms, and shortness of breath. She frequently imagined herself
making embarrassing mistakes or being harshly judged by others. These intrusive thoughts
intensified her anxiety and made her feel even more self-conscious. Sarah expressed a sense of
inadequacy, believing that she was not good enough to be accepted by others. Sarah disclosed
that she tended to isolate herself to avoid conflict. Sarah confirmed that there was a history of
anxiety disorders among her family members, suggesting a potential genetic predisposition.

Verbatim of Case

Counsellor: Good morning. May I know why are you here today?

Sarah: I've been avoiding social situations lately and cancelling plans. It's been really
difficult for me.

Counsellor: I understand. Can you tell me more about why you've been avoiding those
situations?

Sarah: I feel a lot of anxiety and fear when I have to be around people. I worry about what
they might think of me and I'm afraid of embarrassing myself.

Counsellor: It sounds like social situations trigger a lot of anxiety for you. Can you describe
what that feels like?

Sarah: It's like my heart starts racing, I get sweaty palms, and it's hard to catch my breath.
I just feel really uncomfortable and overwhelmed.

Counsellor: Do you have any specific thoughts or images that come to mind when you think
about social situations?
Sarah: Yes, I often imagine myself doing something embarrassing or being judged by
others. Those thoughts make me even more anxious and self-conscious.

Counsellor: It seems like you have negative beliefs about yourself in social situations. Can you
share some of those beliefs?

Sarah: I always think that people are judging me or that I'll say or do something stupid. I feel
like I'm not good enough and it's really hard to be around others.

Counsellor: Can you explain about your relationship with others?

Sarah: I usually don't talk to people. Most of the times I isolate myself. I often avoid conflict
and have a hard time standing up for myself. It affects my relationships with others.

Counsellor: It's important to consider other factors as well. Have you noticed any patterns of
anxiety disorders in your family?

Sarah: Yes, there is a history of anxiety disorders in my family.

After talking with Sarah, me as a counsellor understood her problems and categorised in into
7 elements which are behaviour, affect, sensation, imagery, cognition, interpersonal and drugs.
I create modality profile of Sarah as below:

• Behaviour: Avoiding social situation, cancelling plans.

• Affect: Anxiety and fear around people
• Sensation: Increase in heartbeat, difficulty in breathing, sweaty palms
• Imagery: Imagine of doing something and embarrassing herself in front of others
• Cognition: Thinking that she is not good enough and it's hard to be around others
• Interpersonal: Doesn't mingle around people, isolates herself, couldn't stand for herself
• Drugs/ Biology: Family history of anxiety

As what mentioned in the process of counselling, after creating this modality profile,
counsellor and client should collaborate together to come up with the firing order. Based on the
firing order, intervention will be implemented focusing on the most significant modality first.
In Sarah’s case, after discussing with Sarah, as a counsellor I came up with the firing order as
A-C-B-I-S which are affect, cognition, behaviour, interpersonal and sensation. For treatment,
various techniques from other approaches can be used as same goes to Sarah’s case here. Since
Multimodal therapy is a psychotherapy which basically means an educational based therapy, I
came up with interventions that primarily focusing on educating Sarah on each modality.

To manage Sarah's overwhelming emotions such as her anxiety and fear around people
(affect), relaxation techniques and emotional regulation skills were taught, incorporating
elements of mindfulness and grounding exercises. These techniques, often associated with
approaches such as behaviour therapy. This aimed to help Sarah gain control over her intense
affective responses. Besides, to challenge and modify Sarah's negative thoughts (cognition),
cognitive restructuring or reframing will be used. This technique is rooted in cognitive-
behaviour therapy. This would help Sarah to change her negative thoughts and belief about
herself in social situations from she is not good enough to be around others, into something
more realistic and positive self-perception mindset such as 'I am good enough as others'.

Then, to address Sarah's avoiding social setting behaviour, behavioural activation

strategies will be employed. As Sarah mentioned that she is unable to be involve in social
situations and actively cancelling plan, I would encourage Sarah to engage in small social
gatherings, which would facilitate social behaviour change and confidence-building in the
social setting. For example, I will encourage Sarah to join small friends gathering with 4 - 5
members then gradually I will try to expose her to bigger community such as attending
weddings or other community services. Behavioural activation commonly utilizes in cognitive-
behaviour therapy which can be also used in multimodal therapy.

Furthermore, in the aspect of interpersonal relationship, I will teach Sarah ways to

initiate conversation with people. I will provide Sarah several ways to express her feelings to
someone and stand up for herself. I will also adapt the role play technique in counselling session
where Sarah and I will simulate real-life social situations. For example, I will be acting as a
stranger and Sarah will be acting as initiating a conversation with the stranger (me). By doing
this, Sarah can familiarize herself in the social setting and will learn how to initiate
communication as well as how to stay on conversation with others. Finally, to address
sensation, I will teach Sarah deep breathing techniques and grounding exercises to help her
manage the physical sensations of anxiety. Additionally, desensitization systematic techniques
were employed to gradually expose Sarah to social situations, providing her with a sense of
calm and relaxation during these interactions. Desensitization systematic techniques involve
gradually exposing an individual to feared or anxiety-provoking situations in a controlled
manner to reduce their emotional response and increase comfort by using learned technique.

These are the techniques used in Sarah’s case based on each modality to help Sarah
overcome her social anxieties. After implementing this intervention, tracking of firing order
will take place in fifth or sixth session depending on Sarah’s preference together with
counsellor’s opinion. Then, at the end of the session the BASIC ID order will be reassessed to
see the improvement in client.

Techniques

In the multimodal approach, counselors employ a range of techniques and methods to help their
clients, embracing what is known as "technical eclecticism” (Martin-Causey & Hinkle, 1995b).
This means that they draw from various therapeutic approaches and modalities to address the
unique needs of each individual. A significant aspect of this approach is its psychoeducational
nature, which emphasizes education and learning as integral components of therapy. Rather
than adhering to a fixed list of specific techniques, counsellors tailor their interventions to suit
the specific issues and challenges faced by each client. This flexibility allows for a personalized
and comprehensive approach that takes into account the diverse aspects of human functioning,
ultimately promoting growth and change in therapy.

There are many techniques that can be used in multimodal therapy. Therefore, I have
used Sumari, Tharbe, et al. (2015)’s book for guidance to understand about the techniques that
commonly used in Multimodal therapy. According to this book, techniques in multimodal can
be categorised or based on BASIC ID. For instance, to address behaviour domain or modality,
a counsellor can use counterconditioning techniques. Counterconditioning techniques involve
replacing an undesired response with a more positive or adaptive response through
conditioning processes (John, 2017), such as systematic desensitization or aversion therapy.
For example, let's say someone has a fear of spiders. The therapist might gradually expose the
person to pictures of spiders or have them observe spiders from a distance. As they become
more comfortable, they might progress to being in the same room as a spider or even touching
a spider. Through this process, the person's fear response is gradually replaced with a more
relaxed and calm response, helping them overcome their fear of spiders. Other than that, to
resolve issues based on behaviour aspect, counsellor can also implement negative
reinforcement, positive reinforcement, and punishment techniques where reward and aversive
punishment play major role in shaping a person’s behaviour.

In the aspect of affect or emotion, a counsellor can use expression of emotions and
relaxation techniques. As multimodal therapy is a psychotherapy, counsellor can teach the
client to express their feelings and emotions healthy and constructive manner. For example,
even if the client is angry and wanted to use hard words to express their feelings, the counsellor
can teach client to express her anger in a way that would not hurt others. Then, relaxation
exercise techniques also can be used here where it promotes physical and mental relaxation,
reducing stress and promoting sense of calmness (Sumari, Tharbe, et al., 2015). This technique
not only can be used in counselling sessions but also can be used in client’s daily life
approximately spending 25 minutes on relaxation methods every day.

For sensation, a counsellor can use multiple techniques such as relaxation techniques,
bio feedback, and also through exercising every day. We can also teach clients muscle
relaxation techniques such as tensing and relaxing different muscles groups in the body to
reduce physical tension. Besides, we can also teach client deep breathing techniques such as
focusing on the rate of breath which would eventually help them while having shortness of
breath in anxiety attack. Deep breathing techniques can also help to reduce anxieties,
depression, managing stress and so on (Magnon et al., 2021).

Whereas for imagery domain, counsellor can implement imaginal flooding technique.
Imaginal flooding technique means allowing the client to vividly imagine oneself in anxiety
provoking situation and gradually desensitizing the fear response by promoting habituation.
For example, someone has a fear of flying on airplanes. In an imaginal flooding technique, the
therapist might guide the person to vividly imagine themselves in a specific anxiety-provoking
situation such as being on a plane during turbulence. The therapist would encourage the person
to fully engage their senses and emotions, imagining the details of the situation. Over repeated
sessions, the person's fear response gradually decreases as they become more familiar to the
imagined scenario. This process helps eliminate their fear response and promotes habituation,
allowing them to feel more comfortable and less anxious when facing actual flying experiences.

Furthermore, for cognition aspect many techniques can be used. I would like to give
two techniques as examples. Firstly, cognitive restructuring can be used to identify and
challenge negative thoughts or beliefs and replacing them with more positive and rational ones.
Another technique is thought records or journaling (Utley & Garza, 2011). This technique
involves keeping a record of negative thoughts or situations, identifying associated emotions
and automatic thoughts, and exploring alternative perspectives. Then for interpersonal aspect,
counsellor can use role play techniques where both counsellor and client simulate the real-life
scenarios as what discussed in Sarah’s case. Then, paradoxical techniques can also be used
here. This means encouraging the client to engage in symptoms or behaviours they are seeking
to change, often in exaggerated or humorous way. For drugs or biological aspect, medical
check-up, balance diet and exercises and medication can be used.

Application of Multimodal Therapy in a Cross-Cultural Setting

Multimodal therapy is a therapeutic practise that recognises the importance of cultural

sensitivity and adapts the therapy process to meet the unique needs of individuals from various
cultural backgrounds. Counsellors practicing multimodal therapy understand that effective
therapy requires adapting their communication and counselling style to align with the cultural
norms and individual preferences of their clients (Sumari, Tharbe, et al., 2015).

Counsellors who use multimodal treatment in a cross-cultural situation strive to employ

tactics that are both relevant to and respectful of their clients' cultural values and beliefs. They
acknowledge that cultural factors have an impact on a person's worldview, attitudes, and
behaviours. Counsellors can design a therapy strategy that engages with clients and addresses
their cultural experiences by using culturally relevant strategies. Furthermore, counsellors who
practise multimodal therapy in a cross-cultural setting place an emphasis on creating a
supportive and respectable environment. They consider their clients' cultural peculiarities,
ensuring that the therapeutic environment acknowledges and respects their cultural
backgrounds. This involves attentively listening to clients' viewpoints, understanding their
cultural beliefs, and cultivating an accepting environment (Sumari, Tharbe, et al., 2015).

Multimodal therapy also offers the advantage of flexibility in its techniques, allowing
for a diverse range of approaches that can be adapted to the cultural context of the client.
Counsellors can draw upon various therapeutic modalities and techniques that are most
appropriate and effective for individuals from different cultural backgrounds. This flexibility
ensures that therapy is not only culturally sensitive but also responsive to the unique needs and
preferences of each client. In summary, multimodal treatment is used in cross-cultural settings
by adapting the therapeutic process to the unique requirements of patients from various cultural
backgrounds. By adapting communication styles, incorporating culturally relevant techniques,
fostering a supportive environment, and ensuring flexibility in therapy approaches, counsellors
can provide effective and culturally sensitive care that respects and honours the diversity of
their clients.

Advantages And Disadvantages Of MMT

There are several advantages and disadvantages of multimodal therapy. One key
advantage is its holistic approach, which considers multiple aspects of an individual's
functioning. By addressing various modalities such as behaviour, affect, sensation, imagery,
cognition, and interpersonal relationships, multimodal therapy aims to provide comprehensive
support and treatment. Another advantage of multimodal therapy is its personalized nature. By
tailoring the therapy process to each client's unique needs and circumstances, it promotes a
sense of individuality and encourages client to be more engaged in counselling sessions.
Multimodal therapy also integrates various techniques such as combining diverse therapeutic
approach and tailor treatment.

There are some disadvantages to consider. One challenge of multimodal therapy is its
complexity. It requires counsellors to have a deep understanding of various modalities and
techniques, as well as the ability to integrate them effectively. It is also highly dependent on
counsellor’s skills and expertise as the counsellor will be the guider and educator in this
therapy. Multimodal therapy can be time intensive. Due to its comprehensive and personalized
nature, it may require more sessions and a longer duration for desired outcomes to be achieved.
These are the disadvantages of multimodal therapy (Sumari, Tharbe, et al., 2015).
 Reflection & Conclusion

In my opinion, multimodal therapy is an integrative approach that addresses multiple

modalities to provide comprehensive treatment for clients. I believe it is an effective therapy
that can be utilized in counselling settings because it takes into account various aspects of an
individual. Just like humans are comprised of cells, organs, tissues, and muscles, problems we
face are not solely determined by our thoughts or emotions at a given moment. Instead, they
involve the interconnectedness of all modalities. Multimodal therapy recognizes this
interconnectedness and seeks to address all relevant aspects to promote holistic healing.
However, for a counsellor to hold into this therapy, they need adequate knowledge and great
experience in this field. Multimodal therapy is not as easy as it seems, but it encompasses high
level of complexity while applying it in real professional setting.

To look at Multimodal therapy suitability to use in Malaysia context, I would say it is

highly dependent on the counsellor and clients. The suitability still depends on individual who
are involved in this therapy. It might be suitable to use in Malaysia because Malaysia is a
multicultural and diverse society with a rich blend of ethnicities, religions, and languages.
Multimodal therapy's flexibility and adaptability can allow counsellors to align their
approaches with the cultural norms and values of clients (Sumari, Tharbe, et al., 2015). By
incorporating techniques that are respectful of cultural beliefs, multimodal therapy can promote
inclusivity and enhance the therapeutic relationship. Furthermore, in this modern days
Malaysians are facing various psychological challenges, including stress, anxiety, and
depression. Multimodal therapy's holistic approach, addressing different modalities, can
provide a more comprehensive understanding of individuals' concerns.

However, there are also challenges in implementing MMT in Malaysia context. The
widespread adoption of multimodal therapy in Malaysia may face challenges due to limited
awareness and training among mental health professionals. Efforts to promote awareness and
provide training opportunities would be necessary to ensure its effective implementation and
proper utilization of the approach. The availability and accessibility of resources, such as
qualified counsellors, training programs, and appropriate assessment tools, may vary across
different regions of Malaysia. Therefore, not all places in Malaysia can provide an effective
Multimodal therapy. Overall, multimodal therapy appears to be suitable for implementation in
Malaysia, given its cultural sensitivity, comprehensive approach, and potential for
personalization. However, challenges related to limited awareness and training, and resource
accessibility should be acknowledged and addressed so that MMT can be utilized fully in all
over Malaysia.

In conclusion, multimodal therapy offers a holistic and personalized approach to

counselling by addressing the interconnected modalities of human functioning. By considering
the behavioural, affective, sensory, imagery, cognitive, interpersonal, and biological aspects of
an individual, it aims to provide comprehensive treatment tailored to the unique needs of each
client. Through the integration of diverse therapeutic techniques and a focus on cultural
sensitivity, multimodal therapy has the potential to be an effective and flexible approach to
counselling that promotes holistic well-being and supports clients in their journey towards
positive change.
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