copyright 2007 jeff brooks-harris 1 multitheoretical psychotherapy: a new approach to integrative...
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Multitheoretical Psychotherapy:
A New Approach To Integrative Treatment
Jeff E. Brooks-Harris, Ph.D., ABPPUniversity of Hawaii at Manoa
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Making a Patchwork Quilt
Providing multitheoretical psychotherapy is like making a patchwork quilt. A counselor chooses individual pieces of cloth (strategies) from different types of fabric (theories) and assembles them in a unique pattern.
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Are you multitheoretical?
How many theories do you feel comfortable using to
conceptualize clients or guide interventions?
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Assimilative Integration
• Many integrative therapists choose a foundational theory but use ideas and strategies from other approaches as well.
• Assimilative Integration favors a firm grounding in a single system of psychotherapy and then incorporates techniques from different theories within the preferred orientation.
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Multitheoretical Psychotherapy• Multitheoretical Psychotherapy (MTP) provides a
way to understand the relationship between psychotherapy theories based on the way these approaches focus on different dimensions.
• MTP describes a catalog of key strategies that counselors can learn over time.
• MTP describes a method of integrative treatment planning based on collaborative dialogue with individual clients.
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Introduction to MTPFour Lessons
1. Five Principles for Integrative Psychotherapy
2. Working Interactively
3. Working Contextually
4. Integrative Treatment Planning
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LESSON ONE
Five Principles for
Integrative Psychotherapy
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Integrative psychotherapy should be…
• Intentional
• Multidimensional
• Multitheoretical
• Strategy-based
• Relational
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PRINCIPLE ONE
Intentional Integration• Psychotherapy should be based on intentional
choices• Intentionality should guide a therapist’s choice
of focus, conceptualization, and intervention strategies
• Intentionality supports idiographic treatment, allowing counselors to tailor therapy to the individual needs of each client
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Intentional integration represents a middle ground between intuitive and technical
integration
Intuitive INTENTIONAL Technical
Intuitive Integration Based on the therapists’ clinical wisdom and personal perceptions
Intentional Integration Based on collaborative dialogue with clients and is informed by clinical experience, theory, and research
Technical Integration Based on scientific research or treatment protocols written by experts
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PRINCIPLE TWO
Multidimensional Integration Psychotherapy should recognize the rich interaction
between multiple dimensions within individuals’ lives Integrative psychotherapy supports multidimensional
adaptation in the form of functional thoughts, effective actions, and adaptive feelings that allow clients to adjust to biological, interpersonal, systemic, and cultural contexts
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Cultural Contexts
Social Systems
Interpersonal Patterns
Biology
Thoughts Feelings
Actions
Multidimensional Model of Human Functioning
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PRINCIPLE THREE
Multitheoretical Integration• Integrative psychotherapists utilize diverse theories to
understand clients and guide interventions• Multitheoretical conceptualization allows therapists to view
theories as complementary vantage points to create a comprehensive formulation
• Multitheoretical practice involves combining strategies from different theoretical traditions
• Multitheoretical integration enacts a pluralistic philosophy, emphasizing diversity rather than homogeneity and multiplicity rather than unity
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Multitheoretical Framework for Psychotherapy
Theoretical Approaches Focal Dimensions
Cognitive Thoughts
Behavioral Actions
Experiential Feelings
Biopsychosocial Biology
Psychodynamic Interpersonal Patterns
Systemic Social Systems
Multicultural Cultural Contexts
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PRINCIPLE FOUR
Strategy-Based Integration
• Integrative psychotherapists utilize a wide variety of specific strategies drawn from different theoretical traditions
• Strategy-based integration enacts a pragmatic philosophy, translating theory into action
• Integration occurs when strategies from different theories are combined in practice
• Underlying theories do not need to be reconciled
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Key Strategies• Key strategies are skills or techniques that counselors
use with clients to work toward therapeutic goals• Strategy markers indicate when a particular strategy may
be useful• Expected consequences describe the likely outcome of
using a specific strategy• Key strategies can be learned, practiced, and
implemented with clients
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Cognitive Strategy 9.Encouraging accurate perceptions of
realistic constraints
• Strategy Marker: When clients are focusing on unrealistic hopes that interfere with effective problem solving, it is appropriate to encourage accurate perceptions & proactive choices
• Expected Consequence: If clients are encouraged to recognize realistic constraints, the predicted outcome is more accurate views, more effective responses, & more adaptive choices
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Experiential Strategy 3.Encouraging awareness and expression of
feelings
• Strategy Marker: When clients are unaware of their own feelings, or ignore and suppress them, you should encourage awareness and expression
• Expected Consequence: If awareness and expression of feelings is encouraged, it is anticipated that clients will gain insight from their emotions and consolidate their personal experiences
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PRINCIPLE FIVE
Relational Integration
• Psychotherapy integration should be implemented within the context of an effective therapeutic relationship.
• Different styles of relationships can be developed with clients based on individual needs and preferences.
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Relationship Styles Encouraged byDifferent Theoretical Approaches
Theoretical Approaches Relationship Styles
Cognitive Collaborative Empiricism
Behavioral Social Reinforcement
Experiential Empathic Attunement
Biopsychosocial Health Promotion
Psychodynamic Participant-Observation
Systemic Social Choreography
Multicultural Cultural Consultation
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LESSON TWO
Working Interactively with
Thoughts, Actions, & Feelings
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Maladaptive thoughts, actions, and feelings
are highly interactive
Dysfunctional Maladaptive
Thoughts Feelings
Ineffective
Actions
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Maladaptive Interactions
• Maladaptive Feelings like hopelessness are often associated with…
• Dysfunctional Thoughts like “I’m a loser; no one would want to date me,” and…
• Ineffective Actions like social isolation and withdrawal.
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Adaptive Interactions• Adaptive Feelings—like hope and a
desire to overcome loneliness—are more likely to be associated with…
• Functional Thoughts like “Maybe I’ll meet someone nice at the party,” and…
• Effective Actions associated with overcoming fears and talking to new people in a social setting.
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Working Interactively
• A counselor can work interactively with thoughts, actions, and feelings to promote multidimensional adaptation and change.
• Different points of clinical leverage can be used with different clients or in response to different situations with the same client.
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Cognitive Strategies
• Cognitive psychotherapy focuses on thoughts and uses these cognitions as a point of clinical leverage to encourage multidimensional change.
• Cognitive strategies encourage functional thoughts that are rational, evidence-based, and promote effective adaptation to the environment.
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Cognitive interventions are designed to have a primary impact on thoughts and a
secondary impact on actions and feelings
Cognitive Functional Adaptive
Strategies Thoughts Feelings
Effective
Actions
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Reflecting on Practice
What kinds of cognitive strategies do you use with clients to
encourage functional thoughts?
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Catalog of Key StrategiesCOG-1. Identifying ThoughtsCOG-2. Clarifying the Impact of ThoughtsCOG-3. Challenging Irrational ThoughtsCOG-4. Illuminating Core BeliefsCOG-5. Evaluating EvidenceCOG-6. Testing HypothesesCOG-7. Modifying BeliefsCOG-8. Reinforcing Adaptive Cognitions
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Catalog of Key Strategies
COG-9. Encouraging Accurate PerceptionsCOG-10. Supporting Dialectical ThinkingCOG-11. Fostering Mindful AwarenessCOG-12. Working with ImageryCOG-13. Brainstorming SolutionsCOG-14. Providing PsychoeducationCOG-15. Supporting Bibliotherapy
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Behavioral Strategies• Behavioral psychotherapy focuses on actions
and uses these behaviors as a point of clinical leverage to encourage multidimensional change.
• Behavioral strategies support effective actions or reduce maladaptive conditioned responses.
• Effective actions help people meet their needs, attain their goals, or avoid undesirable consequences.
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Behavioral interventions are designed to have a primary impact on actions and a
secondary impact on thoughts and feelings.
Behavioral Effective FunctionalStrategies Actions Thoughts
Adaptive
Feelings
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Reflecting on Practice
What kinds of behavioral strategies do you use with clients to support
effective actions?
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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
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Catalog of Key StrategiesBHV-8. Assigning Homework
BHV-9. Constructing a Hierarchy
BHV-10. Exposing Clients to Images or Experiences
BHV-11. Fostering Acceptance
BHV-12. Encouraging Commitments
BHV-13. Providing Training & Rehearsal
BHV-14. Coaching & Shaping
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Experiential Strategies• Experiential psychotherapy focuses on feelings
and uses these emotions as a point of clinical leverage to encourage multidimensional change.
• Experiential-Humanistic strategies encourage adaptive feelings, explore personal experiences, and promote awareness and growth.
• Adaptive feelings help people evaluate situations, organize for effective action, and match situations in a proportional manner.
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Experiential interventions are designed to have a primary impact on feelings and a
secondary impact on thoughts and actions.
Experiential Adaptive FunctionalStrategies Feelings Thoughts
Effective
Actions
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Reflecting on Practice
What kinds of experiential strategies do you use with clients
to explore adaptive feelings?
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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
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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
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Reflecting on Concurrent Dimensions
• Do you focus more on clients’ thoughts, actions, or feelings?
• Which of these dimensions do you focus on the least?
• Would you like to learn more about any of these strategies?
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LESSON THREE
Exploring Biological, Interpersonal, Systemic, and
Cultural Contexts
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Where do maladaptive thoughts, actions,
and feelings come from? Dysfunctional thoughts, ineffective actions, and maladaptive feelings are shaped by…
• Biology
• Interpersonal Patterns
• Social Systems
• Cultural Contexts
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Working Contextually
An integrative psychotherapist explores and works within biological, interpersonal, systemic, and cultural contexts to promote adaptation to these environments
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Biopsychosocial Psychotherapy
• Biopsychosocial Psychotherapy focuses on biology, connecting body and brain.
• Biological approaches include health psychology, psychiatry, and body therapies.
• Biopsychosocial strategies encourage adaptive health practices that result in biological health, holistic wellness, and mind-body awareness.
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Reflecting on Practice
What do you do with clients to promote biological health, holistic
wellness, or mind-body awareness?
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Catalog of Key StrategiesBIO-1. Exploring the Effect of Biology on Psychological
FunctioningBIO-2. Recognizing the Influence of Psychological
Functioning on HealthBIO-3. Considering the Interaction between Health and
RelationshipsBIO-4. Understanding Health within a Sociocultural ContextBIO-5. Encouraging Physical WellnessBIO-6. Reducing Substance Use
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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
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Psychodynamic-Interpersonal Strategies
• Psychodynamic-Interpersonal Psychotherapy focuses on interpersonal patterns and perceptions as well as unconscious processes.
• Psychodynamic strategies support adaptive interpersonal perceptions that are accurate and not distorted by past relationships and painful experiences.
• Interpersonal psychotherapy strategies encourage adaptive interpersonal skills that support relationships, help resolve conflicts, and facilitate role transitions.
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Reflecting on Practice
What do you do with clients to explore interpersonal patterns,
encourage clear perceptions, and promote effective relationships?
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Catalog of Key StrategiesPSY-1. Listening to Narratives
PSY-2 . Encouraging Free Association
PSY-3. Identifying Relationship Themes
PSY-4 . Making Interpersonal Interpretations
PSY-5. Honoring Resistance
PSY-6. Exploring Childhood Experiences
PSY-7 . Working Through Past Conflicts
PSY-8 . Identifying Attachment Styles
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Catalog of Key Strategies
PSY-9 . Observing the Therapeutic RelationshipPSY-10. Attending to Subjective ResponsesPSY-11. Resolving Conflicts in the Therapeutic RelationshipPSY-12. Modifying Relational InteractionsPSY-13. Interpreting DreamsPSY-14. Adapting to Interpersonal Losses or DisputesPSY-15. Encouraging New RelationshipsPSY-16. Learning from Termination
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Systemic-Constructivist Strategies
• Systemic-Constructivist Psychotherapy focuses on family systems, social groups, and personal narratives.
• Systemic strategies encourage adaptive social practices that allow individual growth and individuation without threatening the stability of the family system.
• Constructivist strategies encourage adaptive personal narratives that construct meaning in a way that matches a person’s experience and supports positive action.
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Reflecting on Practice
What do you do to explore clients’ family and social systems and help them construct meaning in an
adaptive manner?
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Catalog of Key StrategiesSYS-1. Understanding Problems w/in Social Context
SYS-2. Viewing Families as Systems
SYS-3. Detecting Repetitive Interaction Patterns
SYS-4. Describing the Structure of the Family
SYS-5. Identifying Family Roles
SYS-6. Searching for Multigenerational Patterns
SYS-7. Clarifying Family Belief Systems
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Catalog of Key Strategies• SYS-8. Giving Directives for Strategic Change• SYS-9. Exploring Social Construction of Meaning• SYS-10. Externalizing Problems• SYS-11. Encouraging Adaptive Narratives• SYS-12. Utilizing Clients’ Resources • SYS-13. Constructing Solutions• SYS-14. Orienting Toward the Future
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Multicultural-Feminist Strategies
• Multicultural-Feminist Psychotherapy focuses on culture, identity, gender, and power.
• Multicultural strategies encourage adaptive cultural practices and values.
• Adaptive cultural practices allow people to adjust to cultural contexts without violating values.
• Adaptive cultural values allow individuals to appreciate their own group as well as respecting others.
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Reflecting on Practice
What do you do to understand cultural identity and values or support cultural adaptation?
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Catalog of Key StrategiesMCUL-1. Viewing Clients Culturally
MCUL-2. Clarifying the Impact of Culture
MCUL-3. Creating Culturally-Appropriate Relationships
MCUL-4. Celebrating Diversity
MCUL-5. Illuminating Similarities & Differences
MCUL-6. Recognizing the Impact of Identity
MCUL-7. Facilitating Identity Development
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Catalog of Key Strategies
MCUL-8. Appreciating Multiple IdentitiesMCUL-9. Highlighting Oppression & PrivilegeMCUL-10. Exploring Societal ExpectationsMCUL-11. Supporting Social ActionMCUL-12. Integrating Spiritual AwarenessMCUL-13. Becoming Aware of Therapist’s
WorldviewMCUL-14. Reducing Cultural Biases
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Reflecting on Contextual Dimensions
• Which contextual dimensions do you focus on the most with clients: Biology, Interpersonal, Systems, or Culture?
• Which context do you focus on least?
• Would you like to learn more about any of these strategies?
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LESSON FOUR
Integrative Treatment Planning
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Customizing Treatment
• “The therapist must strive to create a new therapy for each patient.” (Yalom, 2002, p. 34)
• Integrative treatment planning provides a practical method for customizing psychotherapy to the needs of an individual client.
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Where to Focus?
• It is not practical or helpful to focus on several dimensions at once
• You may want to start by focusing on two or three salient dimensions closely related to the problem
• It may be helpful to look at the interaction between a concurrent (TAF) and a contextual (BISC) dimension
• Treatment planning can be used to select a focus that will guide conceptualization and interventions
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Integrative Treatment Planning
1. Conducting a Multidimensional Survey 2. Establishing an Interactive Focus on
2 or 3 Dimensions3. Formulating a Multitheoretical
Conceptualization4. Choosing Interventions from a Catalog of
Key Strategies
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Case Example: MTP for Depression
• Claire is a Japanese-American female in her 50’s• Experiencing symptoms of depression since the
death of her mother just over a year ago• Oldest of three daughters and never married• Claire lived with her mother and was the primary
caretaker while her mother was dying
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1. Conducting a Multidimensional Survey
• After clients have had a chance to describe their concerns, you can explore concurrent dimensions: (1) thoughts, (2) actions, &
(3) feelings.• As well as contextual dimensions:
(4) biology, (5) interpersonal patterns,
(6) social systems, & (7) cultural contexts.
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Claire’s Multidimensional Survey:Concurrent Dimensions
Thoughts: “I can’t go on without my mother.”
Actions: Social isolation from family and friends.
Feelings: Despair, hopelessness, and emptiness.
When asked about feelings of sadness, Claire reported a numb sense of distance from any sadness
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Claire’s Multidimensional Survey:Contextual Dimensions
Biology: Decreased appetite and troubled sleeping.
Interpersonal: Claire had tried to be her mother’s favorite since childhood.
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Claire’s Multidimensional Survey:Contextual Dimensions
Social: As a child, Claire competed with her sisters for her mother’s attention. Her father was a good provider but was emotionally distant. Her father died ten years ago. Her sisters are both married with children of their own.
Cultural: As the eldest daughter in a Japanese-American family, Claire felt an obligation to take care of her parents.
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2. Establishing an Interactive Focus
• After surveying all seven dimensions, choose two or three which will serve as the initial focus for psychotherapy
• The choice of focal dimensions should be based on collaborative dialogue
• Ask the client to begin to monitor the interaction between two focal dimensions
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Claire’s Interactive Focus
• After exploring all seven dimensions, Dr. P. and Claire decided to focus on the interaction between feelings and interpersonal patterns.
• Feelings – Hopelessness and despair.
• Interpersonal Patterns – Claire’s close relationship with her mother may have kept her from developing other sources of social support.
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3. Formulating a Multitheoretical Conceptualization
• For each focal dimension, use a model of conceptualization from a corresponding theory:
(e.g., feelings experiential model,
interpersonal psychodynamic, etc.)• Formulate initial conceptual hypotheses.• Expand your conceptualization with more
information.
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Experiential Conceptualizationfor Claire
Emotion Focused Therapy• Claire’s feelings of hopelessness (“I can’t go on”)
may be interfering with a healthy grieving process• Adaptive Primary Emotion: Sadness• Secondary Emotion: Hopelessness• Recommendation: Help Claire explore and
express her sadness in adaptive ways
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Psychodynamic Conceptualizationfor Claire
Core Conflictual Relationship Theme:• Wish: Claire wanted to be her mother’s favorite.• Response of Other: Claire’s mother maintained a
close bond through strict control.• Response of Self: Claire was dedicated to making
her mother happy and gave up her own goals. Claire cherished the close bond but, later, resented her mother’s control over her life.
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4. Choosing Interventions from aCatalog of Key Strategies
• Emphasize the use of intervention strategies from theories that address focal dimensions:
(e.g., feelings experiential strategies
interpersonal psychodynamic, etc.)• Interventions from seven theoretical traditions
are described in the Catalog of Key Strategies.
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Key Strategies used with ClaireExperiential-Humanistic Strategies
EXP-2. Clarifying the Impact of Feelings
EXP-3. Encouraging Expression of Feelings
EXP-6. Supporting Authenticity
Psychodynamic-Interpersonal Strategies
PSY-3. Identifying Relationship Themes
PSY-4. Exploring Childhood Experiences
PSY-14. Adapting to Interpersonal Losses
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Demonstration ofIntegrative Treatment Planning
1. Conducting a Multidimensional Survey
2. Establishing an Interactive Focus on 2 or 3 Dimensions
3. Formulating a Multitheoretical Conceptualization
4. Choosing Interventions from a Catalog of Key Strategies
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Discussion / Action Plan
• Based on what you learned today, are there ideas you would like to apply to your work?
• What can you do to start thinking and working with clients in a more multitheoretical manner?
• If you provide training or supervision, are there ideas or concepts from MTP you would like to use in training?
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Integrative Multitheoretical Psychotherapy
Jeff E. Brooks-Harris (2008)
Boston: Houghton Mifflin
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Training Videos
Available from Microtraining Associates:
Cognitive
Behavioral
Experiential
Psychodynamic
Multicultural
www.emicrotraining.com
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Contact Information
Jeff E. Brooks-Harris, Ph.D.
University of Hawaii at Manoa
(808) 956-7927
website:
www.multitheoretical.com