The Multidimensional Model of Change – a new way of structuring psychotherapy

Multidimensional Model of Change (the MMC) is a meta-theoretical framework for structuring psychotherapy.

The  Model has been used as a basis for the development of an integrative group treatment for depression, called Emotional Safeness Therapy (EST). The EST has been implemented and successfully run by our team at the Akershus University Hospital, the major Norwegian mental health provider, in the period 2015-2018. You can read more about our work on the development and implementation of the MMC and EST in my article: EST Project – Development of Multidimensional Model of Change and Emotional Safeness Therapy.

The strength of therapeutic variety

As I wrote in one of my previous articles, research shows that the majority of psychotherapists deliver eclectic interventions, combining therapeutic strategies from different theoretical schools. In fact, this kind of psychotherapy has become the predominant and the most popular psychotherapeutic approach of our time. Why is it so?

I think that the answer is quite simple: clinicians want to serve their clients as well as they possibly can. And because each client is a unique human being, the best way to serve the client is to individually tailor and customize each intervention. This is the opposite of the aggressively promoted McDonaldization of psychotherapy, where clients with the same diagnosis/problem are supposed to be met with the same, ready-to-wear standardized protocols/packages.

Yet, individual tailoring and customization of interventions do not fully explain why clinicians search for solutions outside  of their own theoretical approaches. Sometimes they reach pretty far.  So, why do they do that?

Well, let me use a metaphor. Doing psychotherapy is a bit like preparing a dinner. Each cook uses a wide spectrum of measures: weight (of meat), volume (of water), number (of eggs), temperature (of steak), color (of tomatoes), ripeness (of bananas), hardness (of potatoes/cheese), freshness, bitterness, creaminess, crispness, stickiness, flavor etc. Some of the measures are used more frequently than others. And some dishes require the use of many of them, while other just a few. But no measure is better than the others in itself. The value of each depends on what kind of food is to be prepared.

Similarly, various psychotherapeutic approaches propose various theoretical concepts, such as defence mechanisms, schemas, needs, reinforcements, attribution, theory of mind, mentalization, transference, locus of control, values, core beliefs, self-compassion etc. All those concepts are just various ways of describing human psychology. They originate from different theoretical models which offer different perspectives to look from at the same phenomena. And just like different measures used by cooks, different concepts are more or less handy when dealing with different issues within the broad filed of psychology. No concept is better than any other in itself, all depends on the context in which it is used and, of course, of our goals.

So, it’s the complexity of human nature and of the problems, which our clients deal with that accounts for the prevailing tendency to combine approaches. No approach is perfect or universal.  The bigger variety of theoretical lenses at our disposal, the more nuanced picture we can see.

Challenge to variety – between chaos and coherence

There are multiple ways of combining treatments and not every way may necessarily lead to better outcomes.

Technical eclecticism, for instance, consists in simple mixing techniques and exercises that originate from different, sometimes very distant theoretical foundations. The real problem with eclectic blending of techniques is the risk of their functional incoherence, i.e. the risk that the clinician will simultaneously push the client in opposite directions and by that undermine own work.

For example, some approaches, like Cognitive Therapy, promote antecedent-focused emotion regulation strategies, which means that they target the emotion eliciting appraisals. Others, like Acceptance and Commitment Therapy, promote response-focused emotion regulation strategies, which means that they target clients’ responses to emotions, after they have arisen. There are also other treatments,  like Compassion-Focused Therapy, that down-regulate and change negative affect by increasing positive emotions.

All three strategies may be efficient and offer healthy alternatives to maladaptive coping with emotions, like avoidance and suppression. But all three reduce avoidance in totally different ways: either by (1) modifying the intensity of what has been avoided (CT and CFT) or by (2) increasing the ability to face difficult emotions and simultaneously retain control over own, values-guided behavior (ACT).

Different coping strategies  complement each other, but may be incompatible if used simulateneously in the same therapeutic context. You simply can’t learn how to accept difficult feelings when you simultaneously change or down-regulate them. It would be like working out muscles and simultaneously taking off the weights to make exercise easier.

More about the integration of different emotion regulation strategies in my next article on Emotional Safeness Therapy.

Another way of combining approaches is assimilation of one of them into another. Strong proponents of specific therapeutic schools try sometimes to “integrate” alien concepts and models by “translating” them using terms from their own theoretical framework. Those take-overs are just another form of theoretical homogenization of psychotherapy with an explicit or implicit goal to remove conceptual diversity from our field.  Any attempt at “translation” of techniques or models just detaches them from their original conceptual context and changes their function. So, as a result we don’t get combined treatments. What we get is still our own approach, flavored by some dummies of techniques used by other approaches.

The third way of combining treatments is their conceptual integration. An integrative treatment maintains the diversity of its ingredients without losing internal coherence. Integration cannot be done within the theoretical frames of any of the combined approaches (this would mean “translation”, mentioned above), so it requires some meta-theoretical framework. A good example of a successful integration of concepts and techniques borrowed from a wide variety of psychological schools is Dialectical Behavior Therapy (DBT). In this case they are coherently glued by dialectical philosophy and the re-conceptualization of borderline personality disorder as a diagnostic category.

The Multidimensional Model of Change, presented in this article, is just a clinical tool for coherent integration of therapeutic strategies originating from various therapeutic schools.

The Multidimensional Model of Change and the four dimensions of psychological functioning

Looking at a wide spectrum of treatment strategies and clinical concepts, we can notice that they tend to cluster around four basic areas of therapeutic scope:

• • A) Interventions aimed at changing how clients relate to their experiences (thoughts, feelings, memories, bodily sensations);
  • B) Interventions aimed at changing how clients relate to themselves (self-to-self relation);
  • C) Interventions aimed at changing how clients relate to other people;
  • D) Interventions aimed at changing how clients relate to their own, conceptualized lives.

The four areas of therapeutic scope correspond to the four basic dimensions of human psychological functioning. These domains are where mental health problems arise, where therapists locate their focus during the session and where the change occurs.

The four dimensions partially overlap and are strongly interconnected, as is the case with all aspects of human psychosocial functioning. So, although the MMC renders them graphicly as distinct and separate domains, it does so only for heuristic purposes. The truth is that structural models are often the only available way of displaying reality, which is non-structural by its nature.

When we look at specific therapeutic techniques and even at psychotherapeutic schools at a more general level, we can notice that they often differ in the degree to which they address the four dimensions. Usually, each of them provides clinicians with conceptual and technical tools that are more suitable for work in some domains than in others. For example, interpersonal psychotherapy focuses mainly on Dimension C (how people relate to others), while humanistic and existential therapies often center around Dimensions B (self-to-self relation) and D (relation to own life).

It doesn’t mean that you can’t use these approaches to work with problems that belong to other dimensions. Yet then, their conceptual framework and proposed strategies may no longer be equally precise and efficient. Their explanatory value may vary from domain to domain, and you may simply need a different perspective to look from for a clearer view.

It’s a bit like using different languages to describe different realities. There are for instance different snow types that the Inuit people distinguish because their language has the different names that are needed. On the other hand, the English language offers more words to distinguish different types of water. In certain circumstances the ability to differentiate between types of snow may be more advantageous, but in other circumstances the ability to differentiate between types of water may be more beneficial.

Cognitive therapy, for instance, has well-elaborated conceptual models and clinical tools for work with clients’ cognitions (Dimension A). It doesn’t mean that you can’t use this therapeutic toolbox to improve the quality of clients’ interpersonal relationships (Dimension C). But when cognitive therapy is applied to the Interpersonal Dimension (C), it still targets cognitions, just in the interpersonal context (for example client’s thoughts about others, thoughts about what others think about her, social comparisons etc.). Sometimes the work on social cognitions may be an efficient way to improve the quality of clients’ relationships. Yet when emotional problems are linked to ostracism, social alienation or rejection, degradation, exclusion etc the attachment theory,  the social rank theory and theories explaining within-group dynamics may provide you with a more elaborate framework for understanding and adressing the client’s problems.

The two axes of the Multidimensional Model of Change

In the Multidimensional Model of Change the four dimensions of psychological functioning form two axes:

1. Intrapersonal axis, which comprises Dimensions A and D (relation to experience and relation to own life);
2. Interpersonal axis, which comprises Dimensions B and C (self-to-self relation and relation to others).

The distinction between intrapersonal and interpersonal focus in psychotherapy is not a new idea. Its potential consequences for treatment outcomes have been investigated by researchers already in 1990s.

What you may find new and surprising in the Multidimensional Model of Change is the fact that it locates the quality of self-to-self relation on the Interpersonal axis. It may sound counterintuitive to some, but it just indicates that the model is meta-theoretical rather than a-theoretical.

The Self and the Others – axis 2

Within MMC the Self is thought to be a product of the same cognitive (verbal) processes that allow us to distinguish ourselves from others. In other words, the awareness of the Self arises simultaneously with the awareness of other people as distinct from “me”. At early stages of our development, through social training, we learn to make three basic distinctions: (1) me-you, (2) here-there, (3) now-then (they’re called “deictic frames”). The ability to distinguish me-here-now from someone/something- there-then leads to the development of the sense of the Self as distinct from the environment.

Our ability to make the distinction between ourselves and the others and between our location and other places allows us to look at ourselves from the perspective of others. We are simply able to view ourselves as “someone – there” and relate to ourselves in exactly the same way as we relate to others.

Furthermore, the content of our conceptualized Selves (called sometimes “psychological identity”) is a product of socialization. Human beings respond not only to events (stimuli) but also to own responses. We are simply aware of what we are doing and the social environment  provides us with clues, categories and rules for naming, categorizing, interpreting and evaluating our own behaviors, feelings, thoughts and our bodies. In other words, we look at ourselves through the eyes of others, and our self-related narratives are mediated by our socio-cultural environment.

From the evolutionary point of view, the primary function of the Self is to regulate our social interactions. Human beings have evolved as a social species and our survival, safety and access to resources depend on how well we master the social game. Our real environmental challenges are linked to our social functioning as we deal with natural environment collectively. Social skills are a stronger predictor of our wealth and success than our ability to escape predators. And, according to literature, our social skills are based on (1) awareness of own emotions, needs and actions, (2) awareness of how our behavior impacts others, (3) proper identification of our status in the group, (4) ability to control/regulate own verbal and non-verbal reactions in the social context, (5) ability to differentiate and adjust our behavioral rules and self-regulation to continuously changing social situations. The quality of our social functioning depends on self-awareness, self-reflection, self-identity and self-control, i.e. on aspects of the Self.

Although there are many models and theories of the Self, here seems to be a consensus across a broad range of them: our relation to ourselves and our relations to others are two sides of the same coin. That’s why in the Multidimensional Model of Change the Dimensions B and C form the same axis.

CLINICAL APPLICATIONS OF THE MULTIDIMENSIONAL MODEL OF CHANGE

Clinical applications of the Model are a topic for a manual, not a blog article. So, I outline only some basic points here.

The applicability of the Model

The Multidimensional Model of Change provides clinicians with a coherent framework for structuring therapy. From the theoretical point of view, the Model is conceived as an empty frame. Therefore, it can be filled with different theoretical constructs and used with any approach or with a combination of such.

The Multidimensional Model of Change can be applied to structure individual therapy, group therapy, and to coordinate treatment delivered by multidisciplinary teams at in-patient units – across all populations and independently of symptom severity.

The MMC in clinical assessment

Using the MMC in the initial phase of treatment, the clinician systematically assesses client’s psychological functioning in all four Dimensions (A, B, C and D) in order to identify treatment goals in each of them. The diagnosis itself does not provide such guidance. Subsequently, during the treatment, the clinician continuously monitors all dimensions and re-assesses primary targets for the intervention at a given point of time, moving focus swiftly between the dimensions.

Let us look at an example:

THE STORY OF BRIAN (a fictive patient)

Brian was referred to an outpatient unit with a “treatment-resistant” panic disorder and agoraphobia. At the point of the referral he had already went through two unsuccessful treatment attempts. Both resulted in dropout from psychotherapy. He continued on medication, without any improvement.

Brian was a young, fit and healthy man, who grew up in a social environment that cultivated traditionally understood masculine ideals. Already as a young boy he learned to value physical fitness and strength. Brian was always an outdoor person, with little interest in books, and he decided to seek job right after high school.

His first job was at a supermarket. He liked physical tasks, like moving heavy objects, fixing broken shelves and the such. His biggest challenge and the main source of stress was the customer service. Unfortunately, the longer he worked, the more customer-related tasks he was assigned by the boss, who apparently viewed this as a form of job promotion.

One day, when on a bus, he witnessed a young passenger getting a heart attack. Afterwards he learned that the man died in hospital.

A couple of weeks later, while working directly with customers, Brian experienced strong pain in the chest and respiratory problems. He asked his colleague to call an ambulance and was taken to hospital. At the emergency unit he heard the term “panic anxiety” for the first time. There was nothing wrong with his heart. He was referred to a shrink but initially declined to go. Panic attacks became more frequent and he finally quit his job.

Panic disorder is a typical example of a problem located in Dimension A – how the client relates to own bodily sensations and to own catastrophic thoughts. There are some empirically validated protocols for this condition. And yet…. for Brian, panic disorder was not just a Domain A disorder. It was a dramatic change of his self-image: from the brave and strong to the weak and broken one. From an “alpha male” to a loser. The problem quickly contaminated Domain B: self-to-self relation. Brian started to dislike himself and became less self-secure. The first failed exposure tasks only fueled self-contempt and led to the avoidance of further failures. The rule “better not to try than to fail” was an understandable strategy to protect the self-image.

But that’s not all. Problems within Domain B quickly affected Domain C – interpersonal relations. Brian started to feel less masculine than his friends, who apparently didn’t have to call the ambulance because of fright. He became less assertive and less resolved in their company. Gradually, he started avoiding them and withdrew from all social relationships, feeling increasingly isolated and lonely. This happened without any change of the main diagnostic classification of his symptoms (agoraphobia with panic disorder), which still placed his problems on the Intrapersonal axis.

Yet, the MMC-based assessment would point at Domain B (self-to-self relation), and the Interpersonal axis, as the primary target for the initial phase of the intervention.

The MMC in treatment

Even if problems start in Dimension A and are properly diagnosed as belonging there, the treatment does not need to target this dimension in the first place. When any homework threatens the client’s self-image and any failure to meet expectations leads to self-attack, the treatment may start elsewhere. Brian’s path to a vital and fulfilling life does not have to begin from changing his relation to the chest pain, but rather from changing his relation to himself as a person.

Any homework or exposure task, even when done “in the service of personal values”, as well as any attempt to clarify these values, in certain circumstances carry the risk of fueling shame. Thus, an exaggerated focus on the intrapersonal change (Dimensions A and D) may fuel toxic processes on the Interpersonal axis, if the intervention is not properly balanced between all four dimensions.

I recommend you read a supplementary article: The therapist’s ten commandments: First – Do not shame

The MMC with “difficult clients”

Let me introduce Mary (a fictive client), whose father abandoned her and her mother for another woman when she was 11 years old. After that, when Mary was a teenager, her mother had multiple short-term relationships with various men, but none lasted longer than a few months. She also developed alcohol problems and was sometimes away from home for a number of nights. It was the grandmother and two aunts who then looked after Mary. Lack of stability and emotional neglect made Mary often feel unimportant and unwanted, almost “invisible”. This was her predominant emotional experience in adolescence.

She managed to graduate from college and fell in love with “the man of her life” shortly after. The couple married and decided to move out of state to run her husband’s family business, even though it meant for Mary moving away from all her friends. But the new house, with the possibility of working from home, seemed to be a good place for raising kids.

The marriage started to deteriorate shortly after the couple moved, but it took a couple of years before Marry admitted it to herself. She has been left virtually alone, with the full responsibility for business, home and kids, and isolated from all her friends. At the same time her husband engaged in multiple outdoor hobbies and irresponsible economic projects. To one of her closest friends Mary confessed that instead of getting a husband, she got one more irresponsible kid who makes immature decisions affecting the whole family. Mary suggested couple therapy, but her husband reacted with anger. She then started to consider divorce.

The situation changed after Marry got panic disorder and severe agoraphobia. Her illness forced the husband to take over several of her duties, such as driving children to training or even driving her to appointments. He also took over Mary’s place at parents’ evenings at school and at some other events, because she couldn’t leave home alone. Generally, he became more present in the family’s life and started to spend more time at home.

Despite three subsequent treatments delivered by five different psychologists, Mary did not improve. But what would have happened, if she had?

From the technical point of view, the concept of “secondary gains from a disorder” may be correct here. Yet from the MMC point of view, the most important question is: What makes the gain a gain? This kind of question removes blame from the client.

So, looking at Mary through the MMC lenses we can see a woman with unmet emotional needs in Dimension C and an avoidant coping style with interpersonal problems. The way she tries to manage close relationships is affected by the quality of her relation to herself (Dimension B), which is heavily burdened by emotional neglect, rejection and abandonment in adolescence.

So, from the MMC point of view Mary is not a “difficult” client, but a client whose problems were wrongly identified as belonging to Dimension A. The earlier failure of solving them can be compared to the failure of finding water when digging in a wrong place. What Mary needs is help with moving on within Dimensions B and C, i.e. the Interpersonal axis.

The MMC with serious mental disorders and for in-patient settings

The Multidimensional Model of Change was initially conceived as a framework for structuring psychotherapy. However, it can be applied to structuring and planning multimodal treatment at in-patient units and to coordinating the work of multidisciplinary teams.

For instance, while working with psychosis the psychologist’s basic task consists in helping the patient to change the way she relates to her psychotic experiences – delusions and hallucinations (a typical Dimension A task). And the first step is to help the patient to gain some insight into psychosis, which means to distinguish herself from the symptoms and to label them as symptoms.

Insight is a prerequisite for further therapy, but in the acute phase of psychosis patients may be inaccessible for any psychological intervention at all. Then antipsychotic medication may be the only available option for helping the patient to reach the point of basic awareness of own situation.

Although the MMC was created for structuring psychosocial interventions, pharmacotherapy may successfully be included into the framework. Working towards clearly defined and commonly understood treatment goals, psychologists and psychiatrists may coordinate their efforts in Dimension A. For instance, the proper choice and dynamic adjustment of the type and dosage of antipsychotic medication help the patients change the way they relate to delusional beliefs or hallucinatory experiences. Dynamic adjustment means that the same medication which facilitated the process of recovery at early stages of the treatment may be viewed as impeding at later stages if not altered.

Furthermore, the acute phase of psychosis, during the first days of hospitalization, is also the phase when the patient’s relatives worry the most and seek contact with the health personnel. So, even if at that point the patient is not receptive to any psychosocial treatment, the encounters with her nearest social environment may be viewed as an excellent opportunity to initiate the treatment in Dimension C, from the MMC point of view. If we have a clear view of therapeutic goals in Dimension C, there’s a lot to achieve there just by the manner we talk about the diagnosis and build a working alliance with those who are close to the patient.

At an in-patient unit, social workers may undertake various tasks, depending on their clinical background. But typically, their work helps the patient achieve better quality of functioning in the Interpersonal Dimension (C) through facilitating housing, economy and employment. This work may require clarification of the patient’s goals and values in Dimension D, which may be done solely by the social worker, but often entails collaboration with the patient’s primary therapist.

Psychiatric nurses differ in their work experience, professional interests and additional training. Some of them help patients with exposure and other Dimension A tasks, while others lead therapeutic groups, which potentially targets all dimensions. But what all nurses have in common is solid general medical knowledge, which makes them very efficient in teaching patients self-care (Dimension B). By facilitating interactions between patients, nurses also work directly in Dimension C and their observations may provide the whole team with valuable information in the assessment of patients’ problems on the Interpersonal axis.

And finally, let’s look at the last topic in this part: self-stigmatization. This is clearly a Dimension B problem and may be successfully addressed there in less severe cases (look at the story of Brian). However, especially at early stages of treatment, the only available tool for countering self-stigmatization may be an adequate structuring of the treatment environment by the health personnel (Dimension C – interpersonal interactions). Self-stigmatization must always be considered and viewed as a serious secondary psychopathological process. It may impede recovery and in in worst cases contribute to increased suicide risk. Mere awareness of the connection between Dimension C (how the environment responds to illness) and B (how the patient responds to herself) may be sufficient to alter the behavior of the health personnel in the unit. An assessment of the patient’s premorbid functioning on the Interpersonal axis may also reveal proneness to shame and self-stigmatizing attitudes.

So, the Multidimensional Model of Change – if used by the whole team – may help define common treatment goals in all four dimensions of change and clarify the personnel’s roles in pursuing them.

The MMC and therapeutic coherence

The first part of this article emphasizes the importance of functional coherence for efficient treatment delivery. How does the Multidimensional Model of Change deal with this challenge, keeping in mind that it opens for the integration of seemingly opposite strategies?

Again, this is a topic for a book or at least a separate article. But stated briefly, the basic principle of the MMC says that at a given point of time / in a given therapeutic situation, the functional coherence must be retained within each dimension and not necessarily across the dimensions.

This opens for the simultaneous use of seemingly incoherent strategies and techniques, as long as they are applied to different dimensions of psychological functioning.

For instance, the client should not try to modulate the intensity of fear  by self-soothing techniques if she’s going to  learn how to change her maladaptive behavior in the face of these emotions by the exposure-response-prevention strategy (Dimension A). But she can simultaneously respond with self-soothing to shame and self-criticism for failing the exposure task (Dimension B).

Compassion may suppress justified anger at others (Dimension C), especially in clients who demonstrate submissive/dependent personality traits. But compassion towards oneself (Dimension B) does not interfere with learning to express anger at others and being more assertive (Dimension C).

Finally, the therapist can work on weakening the impact of problematic narratives by teaching the client to look at them from a distance (in Dimension A), and simultaneously work on creating new narratives in Dimension D and on enhancing their impact on the client’s emotions and behavior.

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