Copyright 2007 Jeff Brooks-Harris 1 Multitheoretical Psychotherapy: A New Approach To Integrative Treatment Jeff E. Brooks-Harris, Ph.D., ABPP University of Hawaii at Manoa

Copyright 2007 Jeff Brooks-Harris 2 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.

Copyright 2007 Jeff Brooks-Harris 3 Are you multitheoretical? How many theories do you feel comfortable using to conceptualize clients or guide interventions?

Copyright 2007 Jeff Brooks-Harris 4 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.

Copyright 2007 Jeff Brooks-Harris 5 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.

Copyright 2007 Jeff Brooks-Harris 6 Introduction to MTP Four Lessons 1.Five Principles for Integrative Psychotherapy 2.Working Interactively 3.Working Contextually 4.Integrative Treatment Planning

Copyright 2007 Jeff Brooks-Harris 7 LESSON ONE Five Principles for Integrative Psychotherapy

Copyright 2007 Jeff Brooks-Harris 8 Integrative psychotherapy should be… Intentional Multidimensional Multitheoretical Strategy-based Relational

Copyright 2007 Jeff Brooks-Harris 9 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

Copyright 2007 Jeff Brooks-Harris 10 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

Copyright 2007 Jeff Brooks-Harris 11 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

Copyright 2007 Jeff Brooks-Harris 12 Cultural Contexts Social Systems Interpersonal Patterns Biology Thoughts Feelings Actions Multidimensional Model of Human Functioning

Copyright 2007 Jeff Brooks-Harris 13 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

Copyright 2007 Jeff Brooks-Harris 14 Multitheoretical Framework for Psychotherapy Theoretical ApproachesFocal Dimensions CognitiveThoughts BehavioralActions ExperientialFeelings BiopsychosocialBiology PsychodynamicInterpersonal Patterns SystemicSocial Systems MulticulturalCultural Contexts

Copyright 2007 Jeff Brooks-Harris 15 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

Copyright 2007 Jeff Brooks-Harris 16 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

Copyright 2007 Jeff Brooks-Harris 17 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

Copyright 2007 Jeff Brooks-Harris 18 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

Copyright 2007 Jeff Brooks-Harris 19 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.

Copyright 2007 Jeff Brooks-Harris 20 Relationship Styles Encouraged by Different Theoretical Approaches Theoretical ApproachesRelationship Styles CognitiveCollaborative Empiricism BehavioralSocial Reinforcement ExperientialEmpathic Attunement BiopsychosocialHealth Promotion PsychodynamicParticipant-Observation SystemicSocial Choreography MulticulturalCultural Consultation

Copyright 2007 Jeff Brooks-Harris 21 LESSON TWO Working Interactively with Thoughts, Actions, & Feelings

Copyright 2007 Jeff Brooks-Harris 22 Maladaptive thoughts, actions, and feelings are highly interactive DysfunctionalMaladaptive ThoughtsFeelings Ineffective Actions

Copyright 2007 Jeff Brooks-Harris 23 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.

Copyright 2007 Jeff Brooks-Harris 24 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.

Copyright 2007 Jeff Brooks-Harris 25 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.

Copyright 2007 Jeff Brooks-Harris 26 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.

Copyright 2007 Jeff Brooks-Harris 27 Cognitive interventions are designed to have a primary impact on thoughts and a secondary impact on actions and feelings Cognitive FunctionalAdaptive StrategiesThoughtsFeelings Effective Actions

Copyright 2007 Jeff Brooks-Harris 28 Reflecting on Practice What kinds of cognitive strategies do you use with clients to encourage functional thoughts?

Copyright 2007 Jeff Brooks-Harris 29 Catalog of Key Strategies COG-1. Identifying Thoughts COG-2. Clarifying the Impact of Thoughts COG-3. Challenging Irrational Thoughts COG-4. Illuminating Core Beliefs COG-5. Evaluating Evidence COG-6. Testing Hypotheses COG-7. Modifying Beliefs COG-8. Reinforcing Adaptive Cognitions

Copyright 2007 Jeff Brooks-Harris 30 Catalog of Key Strategies COG-9. Encouraging Accurate Perceptions COG-10. Supporting Dialectical Thinking COG-11. Fostering Mindful Awareness COG-12. Working with Imagery COG-13. Brainstorming Solutions COG-14. Providing Psychoeducation COG-15. Supporting Bibliotherapy

Copyright 2007 Jeff Brooks-Harris 31 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.

Copyright 2007 Jeff Brooks-Harris 32 Behavioral interventions are designed to have a primary impact on actions and a secondary impact on thoughts and feelings. Behavioral Effective Functional Strategies Actions Thoughts Adaptive Feelings

Copyright 2007 Jeff Brooks-Harris 33 Reflecting on Practice What kinds of behavioral strategies do you use with clients to support effective actions?

Copyright 2007 Jeff Brooks-Harris 34 Catalog of Key Strategies 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

Copyright 2007 Jeff Brooks-Harris 35 Catalog of Key Strategies BHV-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

Copyright 2007 Jeff Brooks-Harris 36 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.

Copyright 2007 Jeff Brooks-Harris 37 Experiential interventions are designed to have a primary impact on feelings and a secondary impact on thoughts and actions. Experiential AdaptiveFunctional StrategiesFeelingsThoughts Effective Actions

Copyright 2007 Jeff Brooks-Harris 38 Reflecting on Practice What kinds of experiential strategies do you use with clients to explore adaptive feelings?

Copyright 2007 Jeff Brooks-Harris 39 Catalog of Key Strategies 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

Copyright 2007 Jeff Brooks-Harris 40 Catalog of Key Strategies 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

Copyright 2007 Jeff Brooks-Harris 41 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?

Copyright 2007 Jeff Brooks-Harris 42 LESSON THREE Exploring Biological, Interpersonal, Systemic, and Cultural Contexts

Copyright 2007 Jeff Brooks-Harris 43 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

Copyright 2007 Jeff Brooks-Harris 44 Working Contextually An integrative psychotherapist explores and works within biological, interpersonal, systemic, and cultural contexts to promote adaptation to these environments

Copyright 2007 Jeff Brooks-Harris 45 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.

Copyright 2007 Jeff Brooks-Harris 46 Reflecting on Practice What do you do with clients to promote biological health, holistic wellness, or mind-body awareness?

Copyright 2007 Jeff Brooks-Harris 47 Catalog of Key Strategies BIO-1. Exploring the Effect of Biology on Psychological Functioning BIO-2. Recognizing the Influence of Psychological Functioning on Health BIO-3. Considering the Interaction between Health and Relationships BIO-4. Understanding Health within a Sociocultural Context BIO-5. Encouraging Physical Wellness BIO-6. Reducing Substance Use

Copyright 2007 Jeff Brooks-Harris 48 Catalog of Key Strategies 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

Copyright 2007 Jeff Brooks-Harris 49 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.

Copyright 2007 Jeff Brooks-Harris 50 Reflecting on Practice What do you do with clients to explore interpersonal patterns, encourage clear perceptions, and promote effective relationships?

Copyright 2007 Jeff Brooks-Harris 51 Catalog of Key Strategies PSY-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

Copyright 2007 Jeff Brooks-Harris 52 Catalog of Key Strategies PSY-9. Observing the Therapeutic Relationship PSY-10. Attending to Subjective Responses PSY-11. Resolving Conflicts in the Therapeutic Relationship PSY-12. Modifying Relational Interactions PSY-13. Interpreting Dreams PSY-14. Adapting to Interpersonal Losses or Disputes PSY-15. Encouraging New Relationships PSY-16. Learning from Termination

Copyright 2007 Jeff Brooks-Harris 53 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.

Copyright 2007 Jeff Brooks-Harris 54 Reflecting on Practice What do you do to explore clients’ family and social systems and help them construct meaning in an adaptive manner?

Copyright 2007 Jeff Brooks-Harris 55 Catalog of Key Strategies SYS-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

Copyright 2007 Jeff Brooks-Harris 56 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

Copyright 2007 Jeff Brooks-Harris 57 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.

Copyright 2007 Jeff Brooks-Harris 58 Reflecting on Practice What do you do to understand cultural identity and values or support cultural adaptation?

Copyright 2007 Jeff Brooks-Harris 59 Catalog of Key Strategies MCUL-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

Copyright 2007 Jeff Brooks-Harris 60 Catalog of Key Strategies MCUL-8. Appreciating Multiple Identities MCUL-9. Highlighting Oppression & Privilege MCUL-10. Exploring Societal Expectations MCUL-11. Supporting Social Action MCUL-12. Integrating Spiritual Awareness MCUL-13. Becoming Aware of Therapist’s Worldview MCUL-14. Reducing Cultural Biases

Copyright 2007 Jeff Brooks-Harris 61 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?

Copyright 2007 Jeff Brooks-Harris 62 LESSON FOUR Integrative Treatment Planning

Copyright 2007 Jeff Brooks-Harris 63 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.

Copyright 2007 Jeff Brooks-Harris 64 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

Copyright 2007 Jeff Brooks-Harris 65 Integrative 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

Copyright 2007 Jeff Brooks-Harris 66 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

Copyright 2007 Jeff Brooks-Harris 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.

Copyright 2007 Jeff Brooks-Harris 68 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

Copyright 2007 Jeff Brooks-Harris 69 Claire’s Multidimensional Survey: Contextual Dimensions Biology: Decreased appetite and troubled sleeping. Interpersonal: Claire had tried to be her mother’s favorite since childhood.

Copyright 2007 Jeff Brooks-Harris 70 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.

Copyright 2007 Jeff Brooks-Harris 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

Copyright 2007 Jeff Brooks-Harris 72 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.

Copyright 2007 Jeff Brooks-Harris 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.

Copyright 2007 Jeff Brooks-Harris 74 Experiential Conceptualization for 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

Copyright 2007 Jeff Brooks-Harris 75 Psychodynamic Conceptualization for 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.

Copyright 2007 Jeff Brooks-Harris Choosing Interventions from a Catalog 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.

Copyright 2007 Jeff Brooks-Harris 77 Key Strategies used with Claire Experiential-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

Copyright 2007 Jeff Brooks-Harris 78 Demonstration of Integrative 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

Copyright 2007 Jeff Brooks-Harris 79 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?

Copyright 2007 Jeff Brooks-Harris 80 Integrative Multitheoretical Psychotherapy Jeff E. Brooks-Harris (2008) Boston: Houghton Mifflin

Copyright 2007 Jeff Brooks-Harris 81 Training Videos Available from Microtraining Associates: Cognitive Behavioral Experiential Psychodynamic Multicultural

Copyright 2007 Jeff Brooks-Harris 82 Contact Information Jeff E. Brooks-Harris, Ph.D. University of Hawaii at Manoa (808) website: