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

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

She probably didn't want How dare she do this to come because she Thoughts to me! She is so doesn't really like me. I'm inconsiderate and rude! such a loser.

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

I e pect she's stuck in traffic. !t least I ha"e e tra time to prepare dinner

Feelings

ngry

%epressed

n&ious

'elieved

(ossible
behaviour

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

(hone local hospitals

Continue preparing dinner

*o individual reaction is right or wrong. !owever, the way people react to events can often worsen their lives as a vicious cycle . +or e&ample, if someone feels depressed, they react by withdrawing from others, which only worsens their mood further. By identifying whether these reactions are helpful or unhelpful in achieving specific life goals, people can make choices about how to respond to different circumstances.

)hat evidence supports that thought" )hat evidence does not support that thought" Could there be any other e&planations of the situation" If the worst thing were to happen, how bad would that be" )hat would you tell a friend if he or she were in the same situation"

#e dori$i s$ ob$ine$i? , %e unde "e$i $ti ca a$i ob$inut ceea ce "$ dori$i? , #um "a $ti altcine"a c$ "&a$i 'ndeplinit obiecti"ul? , #e se "a 'nt(mpla sau ce se "a modifica dup$ ce "e$i ob$ine ceea ce "$ dori$i? , #e "$ 'mpiedic$ s$ "$ reali)a$i obiecti"ul? , #(nd dori$i s$ "$ 'ndeplini$i obiecti"ul? , #e a$i putea pierde ob$in(ndu&l?

-. .ultimodal ssessment nd Treatment . The B /IC I.%. )hereas many of the psychotherapeutic approaches used today are trimodal 0addressing the familiar affect, cognition and behavior or 1 BC12, the outcomes of several follow,up inquiries have pointed to the importance of therapeutic breadth if treatment gains were to be maintained. ..T addresses this problem by calling the clinician3s attention to no less than seven discrete but interactive modalities. t base, we are all biological organisms 0biochemical4neurophysiological entities2, who behave 0act and react2, emote 0e&perience affectiveresponses2, sense 0respond to tactile, olfactory, gustatory, visual and auditory stimuli2, imagine 0con5ure up sights and sounds and other events in our mind3s eye2, think 0hold beliefs, opinions, values and attitudes2, and interact 0en5oy, tolerate, or suffer various interpersonal relationships2. Thus, ..T provides clinicians with a comprehensive assessment template. By separating sensations from emotions, distinguishing between images and cognitions, emphasi6ing both intraindividual and interpersonal behaviors, and underscoring the biological substrate, ..T is most far,reaching. In addition, as was mentioned above, by referring to these seven modalities as Behavior, ffect, /ensation, Imagery, Cognition, Interpersonal, and %rugs4Biology, the interactive modalities can be easily recalled by taking the first letter of each one to form the acronym 1B /IC I.%.1 7sing this assessment template will help to ensure that the clinician leaves no stone unturned. /tudents and colleagues frequently inquire as to whether particular modalities are more significant 0and thus, should be more heavily weighted2 than others. .y typical response is that, whereas for thoroughness all seven modalities require careful attention, it is the biological and interpersonal modalities that are the most significant. Clearly, the biological modality wields a profound influence on all the other modalities$ unpleasant sensory reactions can signal a host of medical illnesses8 e&cessive emotional reactions 0an&iety, depression and rage2 may all have biological determinants8 faulty thinking, and images of gloom, doom and terror may derive entirely from chemical imbalances8 and

troublesome personal and interpersonal behaviors may stem from various somatic reactions ranging from to&ins 0e.g., drugs or alcohol2 to intracranial lesions. It is, of course, essential when any doubts arise about the probable involvement of biological factors, to have them fully investigated by a qualified professional. Conversely, a person who has no problematic medical4physical problems and en5oys warm, meaningful and loving relationships is apt to find life personally and interpersonally fulfilling. !ence perhaps it is best to picture the biological modality serving as the base of a pyramid that contains each of the modalities, with the interpersonal modality at the ape&. It must be emphasi6ed, however, that the seven modalities are by no means static or linear, but instead e&ist in a state of reciprocal transaction. !ow does a clinician assess each of these modalities" Typically, through the use of a range of questions. +or e&ample, to assess the client3s behavior, the clinician may ask$ 1)hat is this individual doing that is getting in the way of his or her happiness or personal fulfillment 0self,defeating actions, maladaptive behaviors2"1 9r perhaps, 1)hat does the client need to increase and decrease"1 9r even, 1)hat should he4she stop doing and start doing"1 To assess the client3s affect the clinician may ask$ 1)hat emotions 0affective reactions2 are predominant"1 9r, 1 re we dealing with anger, an&iety, depression, or combinations thereof, and if so, to what e&tent 0e.g., irritation versus rage8 sadness versus profound melancholy2"1 The clinician may ask, 1)hat appears to generate these negative affects , certain cognitions, images, interpersonal conflicts"1 nd, 1!ow does the person respond 0behave2 when feeling a certain way"1 'emember, however, that in addition to assessing each modality separately, it is also important to look for interactive processes that occur between and among the modalities 0i.e., the impact that various behaviors have on the client3s affect and vice versa2. To assess the client3s sensations, the clinician may ask$ 1 re there any specific sensory complaints 0e.g., tension, chronic pain, tremors2"1 lso, 1)hat positive sensations 0e.g., visual, auditory, tactile, olfactory and gustatory delights2 does the person report"1 9r, staying with the notion that one must also assess interactions among modalities, the clinician may ask, 1)hat feelings, thoughts and behaviors are connected to these negative sensations"1 It should be noted that assessment of this modality should also include the individual as a sensual and se&ual being and, when called for, treatment interventions should be aimed at the enhancement or cultivation of erotic pleasure. To assess the client3s imagery, the clinician may ask$ 1)hat fantasies and images are predominant"1 1)hat is this client3s self,image"1 The clinician may also assess for specific success or failure images that the client holds, and will certainly want to ask whether the client e&periences any negative or intrusive images 0e.g., flashbacks to unhappy or traumatic e&periences2. 9f course, as with the other modalities, the clinician will also want to assess how the client3s images are connected to ongoing cognitions, behaviors, affective reactions, etc.

To assess the client3s cognitions, the clinician may ask$ 1Can we determine the client3s main attitudes, values, beliefs and opinions"1 nd, 1 re there any definite dysfunctional beliefs or irrational ideas"1 9r perhaps the clinician will assess the client3s predominant 1should statements1 or try to detect any problematic automatic thoughts that undermine the client3s functioning. To assess the client3s interpersonal functioning, the clinician may ask$ 1)ho are the significant others in this client3s life"1 9r, 1)hat does this client want, desire, e&pect and receive from others, and what does he or she, in turn, give to and do for them" The clinician may also ask, 1)hat relationships give this particular client pleasures and pains"1 +inally, to assess the client3s biological dimension, the clinician may ask$ 1Is this client biologically healthy and health conscious"1 1%oes he or she have any medical complaints or concerns"1 nd, 1)hat relevant details pertain to diet, weight, sleep, e&ercise, and alcohol and drug use"1 )hile a client presenting for treatment may use one of the seven modalities as his or her entry point 0e.g., behavior$ 1It3s my compulsive habits that are getting to me1 or interpersonal$ 1.y wife and are not getting along12, it is more typical for people to enter into treatment with problems in two or more of the modalities 0e.g., 1I have all sorts of aches and pains that my doctor tells me are due to tension, I worry too much, and I feel frustrated a lot of the time. I am also very angry with my father12. Initially then, it is usually advisable to engage the client by focusing on the presenting issues, modalities, and4or areas of concern that he or she presents. To deflect the emphasis too soon onto other matters that may seem more important is only inclined to make the patient feel invalidated. 9nce rapport has been established, however, it is usually easy to shift to more significant problems. It should be noted, however, that before fleshing out the details, any competent clinician would likely begin by addressing and investigating the presenting issues 0e.g., 1(lease tell me more about the aches and pains you are e&periencing.1 1%o you feel tense in any specific areas of your body"1 1:ou mentioned worries and feelings of frustration. Can you please elaborate on them for me"1 1)hat are some of the specific clash points between you and your father"12. The multimodal therapist will carefully note the specific modalities across the B /IC I.%. that are being discussed, and which ones are omitted or glossed over. The latter 0i.e., the areas that are overlooked or neglected2 can then be addressed, and often yield important clinical information. Thus, by thinking in B /IC I.%. terms, a clinician or counselor is apt to leave fewer important avenues une&plored. B. /econd 9rder B /IC I.%. )hereas the initial B /IC I.%. is used to translate vague, general, or diffuse problems 0e.g., I feel depressed or an&ious2 into specific, discrete, and interactive difficulties, which can then be addressed with various techniques 0preferably those with empirical backing2, /econd 9rder B /IC I.%. assessments are typically saved for when therapy falters. Every clinician, regardless of his or her level of e&perience, reaches treatment

impasses. )hen this occurs, a more detailed inquiry into the associated behaviors, affective responses, sensory reactions, images, cognitions, interpersonal factors, and possible biological considerations may help to shed some light on the situation. +or e&ample, an unassertive person who is not responding to the usual social skills and assertiveness training methods, may be asked to spell out the specific consequences that an assertive way of living might have on his or her behaviors, affective reactions, sensory responses, imagery, and cognitive processes. 9f course, interpersonal repercussions would also be e&amined and, if relevant, biological factors would be determined 0e.g., 1If I start e&pressing my feelings I may become less an&ious and require fewer tranquili6ers12. ;uite often, this procedure can bring to light reasons behind such factors as noncompliance and poor progress. case in point was a man who was not responding to role,playing and other assertiveness training procedures. 7pon traversing a /econd 9rder B /IC I.%. assessment, he revealed a central cognitive schemata to the effect that he was not entitled to be confident, positive, and in better control of his life, because this would only show up his profoundly reticent and inadequate father. Consequently, the treatment focus shifted to a thorough e&amination of his entitlements. C. Bridging Bridging 0a strategy that is probably employed by most effective therapists2 can readily be taught to novices via the B /IC I.%. foundation. The technique is best described through the use of an e&ample. #et3s say a therapist is interested in assessing a client3s emotional response0s2 to an event. The therapist might ask, 1!ow did you feel when your father yelled at you in front of your friends"1 *ow suppose that instead of discussing his feelings, the client responded with a defensive and irrelevant intellectuali6ation 0e.g., 1.y dad had strange priorities and even as a kid I used to question his 5udgment12. If additional probes into this client3s feelings only yield similar abstractions, it would likely be counterproductive to confront the client and point out that he is evading the question and that he seems reluctant to face his true feelings. Instead, in situations of this kind, bridging is usually more effective. +irst, the therapist would deliberately attune to the client3s preferred modality 0which in this case is the cognitive domain2. Thus, the therapist would begin the bridging technique by e&ploring the client3s cognitive content. The therapist might say, 1/o you see it as a consequence involving 5udgments and priorities. (lease tell me more.1 fter a five to ten minute discourse, the therapist would then endeavor to branch off into other directions that seem more productive. +or e&ample, the therapist may say, 1Tell me, while we have been discussing these matters, have you noticed any sensations anywhere in your body"1 This sudden switch from the cognitive modality to the sensory modality may then begin to elicit more pertinent information 0given the assumption that in this instance, discussing sensory accounts would likely be less threatening to the client than discussing affective material2.

The client may respond to this question by referring to some sensations of tension or bodily discomfort , for instance, 1.y neck feels very tense1 ,, at which point the therapist may ask him to focus on the specific tension. 1)ill you please close your eyes, and focus on that neck tension.1 fter a brief pause, the therapist might say, 1*ow rela& deeply for a few moments, breathe easily and gently, in and out, in and out, 5ust letting yourself feel calm and peaceful.1 +rom here, the feelings of tension, their associated images and cognitions may then be e&amined. The therapist may then venture to bridge into the affective domain. The therapist might say, 1Beneath the sensations, can you find any strong feelings or emotions" (erhaps they are there lurking in the background"1 t this 5uncture it would not be unusual for the client to give voice to his feelings. The client might say, 1I feel angry, and a little sad.1 Thus, by starting where the client is and then bridging into a different modality, most clients then seem to be willing to traverse the more emotionally charged areas they may have originally been avoiding. %. Tracking Tracking is a strategy that may be employed when clients are pu66led by affective reactions. +or e&ample, a client may say, 1I don3t know why I feel this way1 or 1I don3t know where these feelings are coming from.1 The first step in tracking involves asking the client to recount the unpleasant event or incident. In true multimodal form, the client is then asked to consider what behaviors, affective responses, images, sensations, and cognitions come to mind. s was the case with bridging, this technique is best described through the use of an e&ample. #et3s say a therapist is working with a client who reported having panic attacks 1for no apparent reason.1 )orking together, the therapist and client were able to put together the following string of events. The client had initially become aware that her heart was beating faster than usual 0sensation2. This brought to mind a memory of a time in which she had passed out after drinking too much alcohol at a party 0image2. This memory still brought about a strong sense of shame 0affect2. s such, the client started believing that she would pass out again 0cognition2 and, as she dwelled on her sensations, this cognition was intensified and culminated in her panic attack. Thus, in this case, the client e&hibited an /,I, ,C,/,C, pattern 0/ensation, Imagery, ffect, Cognition, /ensation, Cognition, ffect2. Thereafter, the client was asked to note whether any subsequent an&iety or panic attacks followed a similar 1firing order.1 Thereafter she confirmed that her two 1trigger points1 were usually in the /ensation and Imagery modalities. This alerted the therapist to focus on sensory training techniques 0e.g., diaphragmatic breathing and deep muscle rela&ation2, followed immediately by imagery e&ercises 0e.g., the use of coping imagery and the selection of mental pictures that evoked profound feelings of calm2. )hile tracking can be useful in uncovering fairly reliable patterns behind negative affective reactions that clients find pu66ling, clinicians should never assume that these patterns are universal and then use the same treatment techniques, in the same sequence, for all clients. +or e&ample, some clients dwell first on unpleasant sensations 0palpitations, shortness of breath, tremors2, followed by aversive images 0pictures of disastrous events2, to which they attach negative cognitions 0ideas about catastrophic illness2, leading to maladaptive behavior 0withdrawal and avoidance2. It is important to

underscore that this /,I,C,B firing order 0/ensation, Imagery, Cognition, Behavior2 may require a different treatment strategy from that employed with say a C,I,/,B sequence, an I,C,/,B, or some other firing order. Clinical findings suggest that it is often best to apply treatment techniques in accordance with a client3s specific firing order. E. The .ultimodal #ife !istory Inventory fter conducting the initial interview, many multimodal therapists elect to have their clients complete the .ultimodal #ife !istory Inventory 0#a6arus < #a6arus, =>>=, =>>?2. This =@,page questionnaire frequently facilitates treatment 0when conscientiously filled in by clients as a homework assignment, usually after the initial session2, by providing detailed background information and allowing for a more comprehensive problem identification sequence to be derived than would typically occur from the interview alone. The .ultimodal #ife !istory Inventory also generates a valuable perspective regarding a client3s style and treatment e&pectations, and is typeset in such a manner that allows for an easy determination of specific e&cesses and deficits across a client3s B /IC I.%. 9f course, seriously disturbed 0e.g., deluded, deeply depressed, highly agitated2 clients would not be e&pected to comply, but most psychiatric outpatients who are reasonably literate will find the e&ercise useful for speeding up routine history taking and readily provide the therapist with a B /IC I.%. analysis. +. /tructural (rofile Inventory :et another assessment tool for the multimodal therapist is the A@,item /tructural (rofile Inventory 0/(I2. The /(I evolved by generating a variety of questions that, on the basis of face validity, appeared to reflect essential components of the B /IC I.%. 0#a6arus, =>>B2. The /(I yields a quantitative B /IC I.%. graph that depicts a person3s degree of activity, emotionality, sensory awareness, imagery potential, cognitive propensities, interpersonal leanings, and biological considerations 0#a6arus, =>>B2. The /(I may also be particularly useful in couples therapy, where differences in the specific ratings may indicate potential areas of friction. %iscussion of these disparities with clients can result in constructive steps to understand and remedy them. series of studies 0e.g., !erman, =>>A8 #andes, =>??2 have established the reliability and validity of the /(I. 9f special interest is the fact that !erman 0=>>=, =>>B2 has also shown that client,therapist similarity on the /(I is predictive of psychotherapy outcome. .ultimodal therapists may also make use of several other speciali6ed assessment instruments 0e.g., The E&panded /tructural (rofile and The 'evised .arital /atisfaction ;uestionnaire2, which are described in detail elsewhere 0e.g., #a6arus, =>>B2. It should be emphasi6ed, however, that wherever applicable, multimodal therapists will also strive to administer additional well,known 0and preferably, empirically supported2 assessment measures such as the Beck %epression Inventory 0Beck, =>??2, and :B9C/ 0Coodman et al., =>?>2. Top of Page A. Clinical Indications nd E&lcusions

)hile ..T offers a comprehensive orientation that is e&tremely fle&ible and ardently strives to match the best and most effective methods with the appropriate treatments for each individual, there do e&ist several situations in which one may elect not to work multimodally. +or e&ample, as mentioned above, a clinician treating a client with serious psychopathology 0e.g., active delusions, e&treme depression, pervasive an&iety2 would not likely have much luck getting the client to complete the .ultimodal #ife !istory Inventory. In addition, certain situations call for an immediate, highly focused crisis intervention sequence, in which the emphasis would be on methods that are more likely to be limited but intense. /imilarly, there is often no need to delve into broader or deeper issues with clients whose problems call for immediate and obvious interventions. +or e&ample, a business e&ecutive who is uncomfortable flying may seek treatment because her 5ob calls for frequent air travel. In this case, the entire treatment may entail no more than three desensiti6ation sessions coupled with mental imagery and autohypnotic skills that she can use as needed. It is also not uncommon to encounter high functioning individuals whose problems call for a bimodal intervention 0e.g., cognitive restructuring and social skills training2, or who simply need little more than a good shoulder to cry on 0metaphorically speaking2, an active listener, or an authority figure who will affirm their own perceptions or 5udgment, or offer reassurance and good advice. Thus, in practicing ..T, one does not mindlessly apply the multimodal spectrum across the board, but instead, when indicated, the well,trained multimodal clinician has an imposing armamentarium of assessment and treatment strategies at his or her disposal. 'ecall that ..T is a clinical approach that rests on a social and cognitive learning theory, and is therefore not a unitary or closed system. Instead it uses technically eclectic and empirically supported procedures in an individualistic manner. 9bviously, there is no one therapist who can be well versed in the entire gamut of methods and procedures that e&ist today. Therefore it should go without saying that if a problem or a specific client falls outside their sphere of e&pertise, the competent clinician will endeavor to effect a referral to an appropriate resource. Top of Page D. Empirical /upport +or ..T common question is whether there is evidence that ..T 0or any other broad spectrum approach2 is superior to more narrow or targeted treatments. !istorically, the data on this sub5ect have been mi&ed. +or e&ample, in the =>BEs and =>?Es, researchers found that for some disorders, speciali6ed or highly focused interventions were indeed superior to broad,spectrum 0or multimodal,like2 approaches. 9ne e&ample would be the finding that in weight,loss programs a speciali6ed stimulus,control procedure was often superior to multidimensional treatments. Conversely, a strong argument was made for a broad,

spectrum approach in the treatment of alcoholism. !ere, studies found that those treated only by aversion therapy were more likely to relapse than their counterparts who had received aversion therapy plus rela&ation training. It is, of course, far easier to study the impact of a specific technique than to measure the effectiveness of an entire clinical armamentarium such as ..T. *evertheless, colleagues in /cotland and !olland have attempted to do so. +or e&ample, in a carefully controlled outcome study conducted by %r. Tom )illiams, ..T was compared with less integrative approaches in helping children with learning disabilities, with the results clearly supporting the use multimodal procedures 0)illiams, =>??2. In addition, %r. ..C.T. Fwee conducted a controlled outcome study of multimodal treatment on ?D hospitali6ed patients suffering from obsessive,compulsive disorders or phobias, >EG of who had received prior treatment without success, and BEG of who had suffered from their disorders for more than D years 0Fwee, =>?D2. In this case, implementing ..T resulted in substantial recoveries and durable nine,month follow,ups. side from outcome measures, there also is research bearing out certain multimodal tenets and procedures. +or e&ample, as mentioned above, multimodal clinicians often elect to use the /tructural (rofile Inventory 0/(I2. +actor analytic studies gave rise to several versions of the /(I until one with good factorial stability was obtained. +or e&ample, the reliability and validity of this instrument was investigated in a series of studies by %r. /. !erman 0e.g., !erman =>>=, =>>A, =>>B2. 9ne of the most important findings was that when clients and therapists have wide differences on the /(I, therapeutic outcomes tend to be adversely affected 0!erman, =>>=2. Top of Page /ummary .ultimodal therapy draws on the same principles of e&perimental and social psychology, as do other cognitive,behavioral therapies. It emphasi6es that for therapy to be comprehensive and thorough it must encompass seven discrete but interactive modalities , behavior, affect, sensation, imagery, cognition, interpersonal relationships, and drugs4biological considerations. The first letters of the foregoing dimensions yield the convenient acronym B /IC I.%. This results in broad,based assessment and treatment foci. It may be stated that a specific ..T theory is that the reciprocal reactions among and between the seven modalities comprise the essence of human temperament and personality, and point the way to rapid and durable therapeutic tactics and strategies. )henever feasible, multimodal therapy practitioners use empirically supported treatment methods. The therapeutic relationship is pivotal. 'apport and compatibility between client and therapist is the soil that enables the techniques to take root. .ultimodal therapy is technically but not theoretically eclectic. It makes effective use of methods from diverse sources without relinquishing its social learning and cognitive theoretical

underpinnings. +itting the requisite treatment to the specific client 0and not vice versa2 is an essential goal.

Thoughts /omething bad is going to happenH II wonJt be able to copeH

Body reaction drenaline response K BodyJs alarm system , Energised for fight or flight. Blood is diverted to the big muscles to help us escape or fight the threat, and blood is therefore taken away from other body systems. :ou might notice in your body$ !eart rate increases Breathing speeds up, breathless, choking feeling .uscles tense, aching, shaking !ot, /weating #ightheaded, Blurred vision Butterflies in tummy, urge to go to toilet .ore alert K scanning for danger Thinking differently Is this threat a real one or is it really bound to happen" m I e&aggerating the threat" m I misreading things" I feel bad, but that doesnJt mean things really are so bad. )hat would someone else say about this" )hat would I say to a friend in this situation" )hat would be a more helpful way of looking at things" )hereJs my focus of attention" I can cope with these feelings, IJve got through it before. This will pass

Doing differently Take a breath !ow will doing this affect me in the long term" %onJt avoid situations K go anyway. (roblem solve or make plans if necessary. Take things slowly or gradually. +ocus attention outside of me K e&ternal rather than internal focus. )hatJs the best thing to do"

 )hat would help most" Imagine Imagine yourself coping in a situation that you feel an&ious about. /ee the situation through to a successful completion. Visualise blue for calm. Breathe in blue and breathe out red. #isten to this one too$ http$44www.getselfhelp.co.uk4music4+irst id(anic..mpA