The Integrity Model of Existential Psychotherapy in Working with the 'Difficult Patient'

Nedra Lander, Danielle Nahon

• Publisher: Routledge
• Year: 2006
• Print ISBN: 9781583912201
• eBook ISBN: 9781135453268
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Dealing with the therapeutic impasse is one of the most challenging tasks faced by therapists. The Integrity Model of Existential Psychotherapy in Working with the 'Difficult Patient' describes how the Integrity model of psychotherapy provides an original solution to dealing with difficult issues such as resistance, acting out, counter-transference, guilt, value clashes and cultural diversity.

The Integrity model is based on an existential approach to living and views psychological difficulties as stemming from a lack of fidelity to one's values. In this book, the authors explore how this approach to psychotherapy can enhance other therapeutic models or stand on its own to offer a valuable alternative perspective on the causes of mental illness. Case material is provided to illustrate the value of the Integrity model in relation to a range of clinical issues, including:

Borderline Personality Disorders

Antisocial Personality

Post-Traumatic Stress

Schizophrenia

Workplace Stress

Addictions.

This book provides a provocative and insightful presentation of the subject of impasses, as well as dealing with associated issues including the role of values in psychotherapy, community, spirituality, and therapist responsibility. It will be of great interest to counsellors and psychotherapists.

Chapter 1Integrity Therapy and the Integrity modelThe beginning

Integrity Therapy is based on the work of the psychologist O. Hobart Mowrer (1907—1982). Mowrer mentored Nedra for four years; they worked together in offering Integrity groups to students at the University of Illinois, and in the community of Urbana-Champaign, Illinois. Nedra went on to extend the principles of Integrity and evolved the Integrity model. In 1979, we — Nedra and Danielle — began our own collaborative relationship in honouring Mowrer’s legacy in the continued development of the Integrity model.

Mowrer received his PhD in 1932 from Johns Hopkins, and an honorary MA from Harvard University in 1947. He was a national research fellow at Northwestern University and Princeton University, and taught at Yale, Harvard — as director of the Psycho-educational clinic — and for many years as research professor at the University of Illinois at Urbana-Champaign. Mowrer was a pioneer in the areas of learning and behaviour modification, motivation, language, and personality. He served as president of the American Psychological Association in 1953—4. At Illinois, he directed the Lilly Fellowship program focussing on the combined psychological and religious study of the personal problem of guilt (McVicker-Hunt, 1984).

Many of Mowrer’s over 220 publications (McVicker-Hunt, 1984) were centred on his research work in behavioural psychology, in which he played a pioneering role in the development of the two-factor theory of learning (Mowrer, 1941, 1951). Mowrer collaborated with Dollard and Miller on the development of social learning theory (e.g. Dollard et al., 1939). Parallel to his work as a research psychologist, Mowrer began to explore the field of psychotherapy; after investing over 700 hours in his own psychoanalysis, Mowrer broke away from the traditional Freudian perspective. Having spent a summer studying with Harry Stack Sullivan in 1945, Mowrer finally became convinced that the cause of neuroses and other psychiatric disorders lay primarily not in intrapsychic conflicts, but rather in interpersonal attitudes and behaviours (Lander and Nahon, 2000 c).

Mowrer returned to Yale from Washington, DC after the Second World War and began to evolve a new approach towards psychotherapy. Rather than delving into the unconscious, he began to examine the nature and quality of interpersonal relationships (McVicker-Hunt, 1984). Mowrer began to discover that individuals were quite therapeutically responsive to exploring issues of dishonesty with self and others. He began to encourage individuals in therapy to self-disclose, and to self-disclose himself with the hope that his openness would inspire trust in those who found it difficult to self-disclose (McVicker-Hunt, 1984). This process, which he termed modeling (Mowrer, 1970 d), found a profound application in a new therapeutic approach in the treatment of substance abuse. At the University of Illinois, Mowrer and his wife Dr Willie May (Molly) Mowrer - also a professor at the University of Illinois - referred to this group approach as Integrity Groups. These groups comprised what the Mowrers termed a mutual help group approach (Mowrer, 1969 a). At a time when the prevailing model for groups was the analytic model, the Mowrers’ large recovery-oriented Integrity groups played a leading role in spearheading the self-help group movement as parallel and complementary to the 12-step based approaches to the treatment of alcoholism and other forms of substance abuse.

Mowrer is considered “one of the major figures in the self-help movement” (McVicker-Hunt, 1984, p. 913). He was an adviser to several large community-based 12-step recovery programs for substance abuse, including Daytop Village, Inc. (Casriel, 1963) and Synanon (Endore, 1968; Yablonski, 1962). Mowrer was very fond of Alcoholics Anonymous (AA) because he felt that there was a great affinity between AA and his Integrity (Therapy) groups (Mowrer, 1960, 1966, 1969 a). The principles of Integrity Therapy, AA, and many of the related 12-step programs share a strong conceptual link and a similar vocabulary. For example, the well-worn phrase among 12-step recovery programs - “you cannot talk the talk without walking the walk” - was one of Mowrer’s pet phrases (personal communication, 1969). Mowrer published and spoke widely at home and abroad on the self-help group movement (McVicker-Hunt, 1984).

Integrity groups were and still are unique in their conceptualization of the leader’s role in group psychotherapy. Integrity group leaders must acknowledge that they too are “in recovery”, and become participating members of the group. Integrity Therapy was the first to introduce:

• the use of an initial screening interview
• self-disclosure by both the leader and prospective member at this interview
• a contracting procedure.

Integrity Groups are based on the critical importance of honouring contracts, both in the group and in one’s life. Mowrer spearheaded the development of contract psychology, and was an ardent fan of the contract psychology of Pratt and Tooley (1964). He played a pioneering role in the conceptualization and development of the key therapeutic concepts of therapist self-disclosure, therapist authenticity, and the role of morality in psychotherapy — his work preceding that of both Allport and Erikson (McVicker-Hunt, 1984). Mowrer (1964 b) acknowledged that his work had been inspired by Sullivan’s emphasis on interpersonal relationships, and as such was developed in parallel with other frameworks, including Frankl’s “will to meaning” (Frankl, 1955). These, as well as Adler’s (1964) concept of social interest and Jung’s (1933) emphasis on the “importance of ‘human decency’ and the pathogenic dangers inherent in deception” (p. 32), were all based on a breakaway from the traditional Freudian view, embracing instead the importance of interpersonal relationships and the positive aspects of morality (Mowrer, 1976).

Mowrer spoke of the connection between psychology and religion/ spirituality: religion’s root word is the Latin word religare, which is also at the root of ligament and ligature. Mowrer suggested that religion (re-ligion) means literally a reunion, rebinding, reintegration, and reconnection (Mowrer, 1961 a, 1969 a). Mowrer introduced the concepts of both community (Mowrer, 1960, 1969 b) and re-ligare (Mowrer, 1958, 1959, 1969 b) in psychotherapy. For Mowrer, therapy called for a return to community through improved communication with “significant others” (Mowrer, 1958; Sullivan, 1953), and a commitment to a more responsible and mature lifestyle.

Mowrer (1960, 1966, 1969 a, 1973) offered beginning pragmatic validations for Integrity Therapy, including: (a) Alcoholics Anonymous; (b) the Synanon recovery groups for drug addicts spearheaded by C. Dederich; (c) the Daytop Village recovery program for substance abuse; and (d) Glasser’s (1969) applications in setting up “guided interaction groups” in public classrooms. In the 1960s, Mowrer changed the term “Integrity Therapy Groups” to “Integrity Groups”, as he felt that Integrity went beyond therapy; it was a way of life and living.

History and evolution of Mowrer’s Integrity (Therapy) groups

Mowrer’s educational focus

Mowrer (1941) frames the presentation of his two-factor learning theory as a means of addressing the Second World War emergency need for national US preparedness in training men and women. In response to this call, he proposes a more global treatise on the learning process. Mowrer highlights the role for educators in supporting the peace effort. He characterizes education as a purveyor of both knowledge and the values of a people through an “educational reconstruction” (Mowrer, 1943, p. 177), which he suggests be carried out by the United Nations. He speaks of an association between freedom, responsibility, and the manner in which questions of value and of service should be addressed in a democracy. He emphasizes the need for a new morality and vision to emerge from the war, pointing out that in the French language, “morale” means both morality and morale - thus underlining the strong correlation between these two concepts which will play an important role in his future therapeutic work.

Transition from learning to a global theory of personality

Mowrer increasingly shifts from a focus on learning towards a new conceptual paradigm of personality and its global components within the full spectrum of its intrapsychic, interpersonal, and cultural determinants. In 1944, he introduces the notion of the communal components of personality, which encompass biological, social, cultural, and physical influences. Mowrer (1944) points to compatibilities between his new theories and the thinking of several key figures in the history of psychology. He agrees with M. A. May’s (1930) notion that one can define personality in terms of an individual’s impact on others, and with Margaret Mead’s (1930) as well as Alexander’s (1942) emphasis on the importance of parental influences on childhood development. He points to the compatibilities between his concept of communal personality and Eric Fromm’s (1941) notion of social character.

In 1952, Mowrer’s paper entitled “Learning Theory and the Neurotic Fallacy”, delineating his transition between learning and psychopathology, is published. Here, Mowrer calls into question the Freudian view that the neurotic suffers from fears which are unrealistic and excessive. He challenges Karen Horney’s (1937) view that neurosis is reinforced by vicious cycles. He interprets Horney’s hypothesis to suggest that neurosis stems from what he terms “a learning excess” (Mowrer, 1952, p. 680), and proposes the contrasting view that neurosis comprises “a learning deficit” (p. 680), whereby the ego remains immature and dominated by the id. Mowrer suggests that the neurotic, much as the psychopath, does not learn, and suffers not from childish fears, but from a genuine fear of being found out for bona fide deceits and deceptions (Mowrer, 1959, 1976). Consequently, the neurotic underlearns. “To put this matter somewhat paradoxically but succinctly, the neurotic is an individual who has learned how not to learn” (Mowrer, 1952, p. 681, original emphasis).

Here, the beginnings of Mowrer’s existential roots - although he never identified himself as such - become evident. He articulates the view that many neurotics suffer from a sense of meaninglessness and helplessness. He suggests that the neurotic has “bartered his sense of freedom to the devil for the dubious comfort of feeling no responsibility, no guilt” (Mowrer, 1952, p. 688), citing the work of such thinkers as Kierkegaard who propose that freedom implies responsibility and the capacity to feel guilt. Mowrer proposes that if therapy acts to diminish guilt, it will likely lead to an increase rather than a decrease of the neurotic symptoms. He argues that in order to camouflage their mechanisms of duplicity and deception, neurotics tend to sever their connection with others and with their own feelings of guilt - concluding that “Thou shalt not bear false witness’ and ‘Know thyself,’ know, acknowledge, communicate with yourself, may yet guide us to surer ground in our quest for psychological healing and wholeness” (Mowrer, 1952, p. 689, original emphasis). These are the seeds of Mowrer’s Integrity Therapy which he will further articulate in upcoming years.

Towards a new theory of psychotherapy

Mowrer (1953 a) states that psychotherapy’s aim should be to help neurotic individuals make their repressed guilt conscious a...

Table of contents

• Cover Page
• Half-Title Page
• Title Page
• Copyright Page
• Disclair
• Table of Contents
• Acknowledgements
• Preface
• Introduction
• 1 Integrity Therapy and the Integrity model
• 2 Lander and Nahon’s Integrity model
• 3 The Integrity model in practice
• 4 Transference and countertransference
• 5 Working with the borderline personality disorder
• 6 Working with the antisocial personality
• 7 Working with the addict
• 8 Working with post-traumatic stress
• 9 Working with the schizophrenic, schizotypal, or psychotic-core individual
• 10 Working with cultural diversity
• 11 Workplace stress and burnout
• 12 Dealing with organizational stress
• Conclusions
• Afterword
• Notes
• References
• Author index
• Subject index