A multimodal approach to stress management and counselling

by Stephen Palmer


INTRODUCTION
One of the problems I originally encountered training practitioners in the field of occupational stress management and counselling was ensuring that they undertook a thorough assessment of their clients. It is too easy to overlook relevant details if only cognitions or specific behaviours are examined. On investigating many different therapeutic approaches I read about Multimodal Therapy (Lazarus, 1981). This approach appeared to offer an assessment and treatment/training programme that could easily be adapted to the field of stress management and counselling (Palmer and Dryden, 1991, 1995). The approach was developed by Arnold Lazarus who was formerly a well known behaviour therapist who had worked with Joseph Wolpe. Even though Lazarus found behaviour therapy quite effective it was not always successful and he believed that important details were overlooked in the assessment procedures. He later went on to develop multimodal assessment and therapy which he asserts covers all aspects of an individual's personality.

RATIONALE & METHOD

The basic framework comprises the following seven modalities:

  • Behaviour
  • Affect
  • Sensation
  • Imagery
  • Cognition
  • Interpersonal
  • Drugs/biology

This blueprint is known by the acronym BASIC ID and is used for the basic assessment of clients. During the assessment the different modalities are examined by asking questions similar to the following:

B- What would you like to start doing/stop doing?
A- What makes you angry, sad, etc?
S- What do you like/dislike to hear, taste, etc?
I- What do you picture yourself doing in x weeks, x years?
C- What are your main musts, shoulds, beliefs?
I- How do you get on with others; do you act passively etc?
D- Do you take medication? Do you smoke? How is your health?

To aid assessment and to make the most use out of therapeutic time, at home clients complete an in-depth 15 page questionnaire which focuses on life history and the different modalities. It also asks the client what approach he/she would like the trainer/counsellor to take e.g. 'I would like a hard working, no nonsense approach'. The counsellor then adapts his/her approach to the needs of the client thereby helping the therapeutic or training alliance. The techniques most frequently used from each modality are in Table 1.

TABLE 1 Frequently used techniques (adapted from Lazarus 1981)

 

BEHAVIOUR  
Behaviour rehearsal, Exposure programme

Modelling, Reinforcement programmes

Self-monitoring and recording, Shame attacking

Empty chair, Fixed role therapy

Psychodrama, Response prevention/cost

Stimulus control, Paradoxical intention

 

 
AFFECT  
Anger expression, Anger/anxiety management

Feeling identification

 

 
SENSATION  
Biofeedback e.g. GSR, biodots, Hypnosis
Relaxation training, Threshold training
Meditation, Momentary relaxation
Sensate focus training, Relaxation response
Massage
 
IMAGERY  
Coping imagery, Time projection imagery
Anti-future shock imagery, Mastery imagery
Positive imagery, Thought stopping imagery
Aversive imagery, Associated imagery
 
COGNITIVE  
Bibliotherapy, Cognitive rehearsal
Disputing irrational beliefs, Problem solving
Challenging faulty inferences, Constructive self-talk
Thought stopping
 
INTERPERSONAL  
Assertion training, Contingency contracting
Fixed role therapy, Communication training
Friendship/intimacy training, Social skills training
Role play, Graded sexual approaches
Paradoxical intention
 
DRUGS/BIOLOGY  

Lifestyle changes, Stop smoking programmes
Diet, Weight control
Exercise, Medication
Referral to specialists

 

Table 1 includes the most commonly used techniques. However, the list is not exhaustive and many other techniques are used by competent practitioners (see Palmer and Dryden, 1995). Once the client's problems and therapeutic/training goals are assessed, appropriate techniques are discussed and selected with the client e.g. the client may prefer to try hypnosis instead of the Benson Relaxation Response for tension. A Modality Profile is produced in which the client's problems and the agreed interventions are recorded. Table 2 illustrates a typical Modality Profile of a Type A client who was referred for stress management to reduce high blood pressure.

TABLE 2 Modality Profile of Type A client with high blood pressure.

MODALITY PROBLEM PROPOSED TREATMENT
Behaviour Type A behaviour: quick Behavioural education. talking/eating/walking. Polyphasic behaviour
Impatient
Behavioural education.
Do one task at a time;
Examine irrational beliefs that may cause polyphasic, 'hurry up' behaviour.
Dispute irrational beliefs
Affect Feels angry at work Anger management.
Sensation Physically tense Biofeedback and relaxation training.
Imagery Images of losing control Coping imagery.
Cognition I must always reach my deadlines otherwise it will be awful. Others must recognise my contribution I can't stand not getting what I want. Beliefs of low self-esteem Dispute irrational beliefs; failure attacking exercises; coping-statements
Teach self-acceptance
Interper- sonal Passive-aggressive Spends little time in recreational pastimes with family or friends Assertion training. Discuss benefits.
Drugs/ Biology High blood pressure
Headaches Overweight alcohol a week Smokes 30 cigarettes a day
Liaise with medical specialist about medication and treatment programme.
Relaxation training.
Weight reduction programme.
Reduction programme- use drink diaries Stop smoking programme.

The client and counsellor/trainer negotiate which interventions to use first depending upon health related priorities and what is manageable and not overwhelming for the client.

CONCLUSION
Today I hope that I have given you some insight into what happens to clients once they have been referred to my Centre for stress counselling or training if they are suffering from stress related disorders. A part of the assessment may also include the use of the Occupational Stress Indicator (Cooper et. al., 1988). I have not had time today to discuss other techniques and methods that a multimodal stress counsellor and trainer may use in 'one-to-one' or group situations. Those of you interested in the approach may find Structural Profiles, tracking and bridging interventions very helpful in your area of work. I can only refer you to the relevant publications (Lazarus, 1981; Palmer and Dryden, 1991; Palmer, 1992; Palmer and Dryden, 1995).

REFERENCES
Cooper, C. L., Sloan, S. J., and Williams, S. (1988). Occupational Stress Indicator. Windsor:NFER-NELSON Publishing.
Lazarus, A. A. (1981). The Practice of Multimodal Therapy. New York: McGraw-Hill.
Palmer, S. and Dryden, W. (1991). A multimodal approach to stress management. Stress News, Journal of the International Stress Management Association (UK) 3, 1, 2-10.
Palmer, S. (1992). Multimodal assessment and therapy: a systematic, technically eclectic approach to counselling, psychotherapy and stress management. Counselling, 3, 4, 220-224.
Palmer, S. and Dryden, W. (1995). Counselling for Stress Problems. London: Sage.
Copyright, S. Palmer, 1995.

(**Article based on a paper presented at the International Stress Management Association (UK) 'Cost and Benefit' Conference at the University of York, 1 July 1994. Published in the conference proceedings.)

Correspondence: Centre for Stress Management, 156 Westcombe Hill, Blackheath, London, SE3 7DH.

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