O. H. Mowrer's Theory of Integrity Therapy Revisited

V. Edwin Bixenstine

• Publisher: Routledge
• Year: 2014
• Topic: Psychology
• eBook ISBN:
  9781317950639
• Subtopic: Mental Health in Psychology
• Index: Psychology

In the mid 20th century, O. Hobart Mowrer was a celebrated academic psychologist, owing largely to his experiments with animals and humans that led to breakthrough theories on how we learn. His numerous publications in this arena propelled him to the post of President of the American Psychological Association in 1954. His own battles with depression led him to develop a new theory of psychotherapy, which he called Integrity Therapy. The premise of this modality is that the client's deception with people they care about is the source of conscience pangs, but the client resists or represses the prompting of the conscience and this causes his or her psychological symptoms. Treatment, therefore, consists of urging the client to acknowledge his or her hidden behaviors to themselves and to significant others that they might both gain restored community with intimates and the fruits of personal integrity and inner peace ( to come clean about their deceptions and rewarding the confession with approval.)

This book explores the conceptual underpinnings of Integrity Therapy and Mowrer's unique treatment approach, detailing his methods for setting conditions for therapy, assessing clinical data, rules of engagement for transference and countertransference, and handling client resistance. Case examples and transcripts are included to demonstrate key points of this technique. Mental health professionals interested in Mowrer's ideas or the history of psychotherapy will find this book to be a valuable and interesting resource.

Part I
The Therapeutic Process

1
Preview of Concept

A Point of Departure

We may think there is willpower involved, but more likely the change is due to wanting the new addiction more than the old one. Wanting the new me in preference to the person I am now.

—Dr. George Sheehan, running guru

Part I (“The Therapeutic Process”) is focused on clinical experience, while Part II (“The Nature of the Problem”) turns to concept. Experience and concept never stand alone. Pure concept has no substance, and pure experience has no meaning. The challenge is to mix concept and experience such that instructor and student communicate with each other.

In my earliest draft of this book, I placed the more conceptual focus (Part II) first. The rationale was that concept would serve as a clarifying framework for the process that was to follow. Students who used the first draft as a text persuaded me to change the order. Their argument was that reading the “hands on” therapy process chapters helped them to better understand and evaluate the more abstract (conceptual) matters. Besides, they pointed out, the process chapters were closer to their initial concerns and interests. They had already read quite enough theory. They wanted the raw, experiential stuff of clinical application.

Two additional reasons for the present order came to the fore. First, it more nearly replicates the instructional sequence, which I found valuable in clinical training, where you immerse the student in actual clinical work and then place that practical experience into a conceptual context. Second, few start with theory and deduce clinical applications from it, though that does have an appeal to logic. Human nature is more experience-bound so that, ordinarily, we start with specific clinical circumstances and build or adopt theory to accommodate those experiences.

The revised order, however, left me with a minor dilemma. Readers need some initial and explicit framework against which to evaluate the process chapters. Might this dilemma be resolved by presenting a conceptual synopsis of Mowrerian theory, telling the reader in base essentials what is told in detail later? While we have touched on critical aspects of Mowrer’s theory in the Introduction, we do well to draw together here what might be termed a basic scaffolding to facilitate a better and earlier grasp of the processes distinctive to applying Integrity Therapy. While this may not recapitulate the rich, interactive spiral between experience and concept permitted in a clinical practicum, hopefully it does move us a step closer.

Conceiving the Normal

Psychotherapy is designed to restore psychological health or normality. What is that? Normality is the absence of psychopathology, or so it has been assumed. Such is the legacy of the medical model. In medicine, health is assumed when laboratory tests are negative. Would it not be valuable to have a positive test for health? In the field of human behavior, such has been the aspiration of many.

Before essaying a definition, let us set forth the conceptual standard against which to measure the positive presence of normality. That standard we will call the integrative principle.¹ Simply put, integration is the choice of actions that bring maximum satisfaction of one’s interests and values over time even though that choice may incur considerable dissatisfaction immediately. Commonplace examples of such behaviors are eating a healthy diet, forgoing a pleasure gained at an associate’s expense, exercising regularly, and engaging in effortful work.

Integration is sometimes, though not always, in contest with another behavioral standard that we will call the adjustment principle. Adjustment promotes choices that lead to maximum immediate satisfaction. Obviously, there will be occasions when what is instantly most rewarding to do will at the same time endanger long-term goals and values. Commonplace examples of behaviors where adjustment is in conflict with integration are overeating or eating unhealthy foods, taking advantage of an associate, sedentary pursuits, and work avoidance.

We could employ the integrative standard unconditionally and say that persons are normal who behave integratively and non-normal if they depart from integrative behavior. Such stringency in applying our positive test, however, would restrict normality to a small if not vanishing class of persons. In adjusting (seeking immediate satisfaction), everyone fails to integrate at least part of the time and for a number of reasons. For one, we do not always discern which choice before us serves our basic interests and values and, as a result, choose whatever immediately costs least or satisfies most. Another factor is that we may not yet have learned that a class of choices has consequences of importance to us beyond the moment. Still another is that we may not have articulated our interests and values, leading to ambiguity about choice. Finally, we may have developed cognitive and perceptual habits that serve to negate, distort, or simply fail to attend to long-term values that are in conflict with momentary wishes.

In light of these considerations, we advance a positive test for normality that rests on the integrative principle but does so conditionally. Normality is that set of behaviors (including emotions, attitudes, and cognitions) that results in a preponderance of integrative over conflicting adjustive choices. This definition permits some adjustive but non-integrative choices to be present in the life of the normal person so long as the predominant feature is integrative behavior. Thus, using our commonplace examples, one may remain normal and yet occasionally overeat or eat unhealthy foods, abuse a friend, loaf around, and skip work. Non-normality enters when such actions predominate, leading, over time, to cumulative life outcomes more dissatisfying than rewarding.

Conceiving Psychopathology

Having advanced a definition of normality, are we at liberty to reverse custom and define pathology as the absence of normality? If we did so, we would find that we exclude a class of persons whose actions observe the integrative principle in the main but who have pockets of chronic adjustive/non-integrative habits. We would be on shaky ground to claim they are non-normal, but equally so to claim they are free of pathology. Here, we seem to have persons who are both normal and pathological.

All right, we may not claim that all normals are free of psychopathology, but can we claim that all non-normals suffer psychopathology? We can answer this question by posing another. Do we not have persons who are free of guilt, anxiety, depression, perceptual and cognitive distortions, and other such symptoms of psychopathology, yet who are predominantly adjustive/non-integrative in their life course? Yes, we do, and these persons have been a thorn in the side of behavioral taxonomists from the beginning. They are definitely not normal, yet they have a “mask of sanity” (Cleckley, 1982) that confounds those who would assign pathology to them. They are both non-normal and pathology-free.

Are we saying that normality and pathology are independent dimensions? Yes, they are in some measure, but not entirely so. Advancing a positive test for normality teaches us that violence is done to either classification concept when defined as the absence of the other. Clearly, we need to have a positive test for both normality and psychopathology. Let us proceed to a definition of the latter.

While the integrative principle usefully serves as our standard for measuring normality, it is the adjustment principle that serves well as the standard for psychopathology. Not all behaviors maximizing immediate satisfactions are relevant, only those which also result in eventual, cumulative dissatisfaction. In other words, psychopathology springs from adjustive but non-integrative choices and actions. However, psychopathology is not identical to adjustive/non-integrative behaviors because it applies only to a particular class of such actions.

Psychopathology is, first, the repeated or habitual choice of adjustive/non-integrative behavior where, second, that repetition is aided and maintained by behaviors chosen to minimize or avoid detection and sanction by others as well as to avoid the individual’s own self-monitoring (guilt, anxiety). It is important to note that chronic choice of adjustive behavior, even when it eventuates in undesirable costs, is not per se pathological. It is the presence of self-deception, aimed at avoiding guilt, and other-deception, designed to avoid social sanctions, which transports such behavior into the domain of psychopathology.

In other words, psychopathology rests in behavior designed to protect adjustive choices from the corrective and inhibitive application of consequences. It is also important to note that these habits of deception of self and others are themselves classified as adjustive but non-integrative in nature. Psycho-pathology is never a simple departure from integrative, future-serving behavior in favor of adjustive, impulse-serving actions. It is always a compound of adjustive/non-integrative behaviors built on the hope that life’s consequences, one’s reality, may at last submit to one’s wishes.

Of course, persons who engage in chronic adjustive/non-integrative behavior, even when not psychopathological, are often disturbing to us. We find them unreliable, self-serving, immature, manipulative, and, sometimes, dangerous. As a result, we often conclude that there must be something psychologically wrong with them and assign them a place in our taxonomy of psychopathologies. This conclusion has played havoc with our better understanding of the psychopathology concept and, consequently, with a clear and powerful classification system.

The truth is, not all persons who disturb us are themselves disturbed. That does not mean they are normal. It may mean that their development is so abnormally arrested and primitive that they fail to entertain outcomes not immediately evident to them and therefore fail to experience that anticipatory sense of consequence that we call guilt. Theirs is not a problem for a psychotherapist addressing psychopathology. Theirs is a problem for the school, the family, the church, and the criminal justice system. Psychologists and other social scientists may usefully contribute to helping these social institutions address the challenges posed by such non-normal but pathology-free persons, but not in the role of psychotherapists.

Pathology as Addiction

The Mowrerian conceptions rendered above comprise, in essence, an addiction theory of psychopathology. An addiction is actually composed of two sets of compulsive habits. One set secures some immediate and relatively momentary satisfaction or relief. The other set facilitates access to and reduces the experienced costs of the first set. For example, alcoholism is not only a matter of compulsive drinking and inebriation. It is also those rationalizations that minimize personal responsibility, those plans that merge alcohol with ordinary work or social pursuits, and those arguments arrayed to deny alcohol dependence or alcoholism.

I offer the following definition: An addiction is (1) the repetitive choice of behavior that brings momentary pleasure, comfort, and relief at a postponed cost greater than those momentary gains and (2) the presence of habits designed to secure access to the addictive act while minimizing the anticipation of costs. Let me repeat in juxtaposition here the definition of psychopathology offered previously: Psychopathology is, first, the repeated or habitual choice of adjustive/non-integrative behavior where, second, that repetition is aided and maintained by behaviors chosen to minimize or avoid detection and sanction by others as well as to avoid the individual’s own self-monitoring (guilt, anxiety). While we deliberately constructed the definition of addiction using language common to that metaphor, it is clear that the substructure of these two definitions is of the same genre.

The classical addictions, such as alcoholism and smoking, are specimens of psychopathology that also serve well to illustrate the essential features of the class to which they belong. Alcoholics and smokers gain satisfaction immediately but at a serious, delayed price. They minimize that cost through managing the response of others and distorting their own personal judgment. For example, alcoholics often hide and disguise their drinking as incidental to normal social intercourse. Smokers often smoke away from the oversight of significant others. Self-deception is illustrated when alcoholics insist they have drunk less than is actually the case, while smokers are quick to exploit through self-delusion whatever uncertainty exists that smoking injures health.

What sets apart the classical addictions from other psychopathologies is a relatively minor feature. The classical addictions involve the ingestion of a substance that in time alters body metabolism. The altered metabolism causes distress experienced for a measured period following deprivation of the substance. Many have relied on substance withdrawal pain as the key to understanding the compulsion in addictions. This reliance is misplaced. Far more pertinent is the loss of psychic income lasting much longer into the future than the two-week span it takes for substance withdrawal pain to subside. When addicts substitute integrative for adjustive/non-integrative behavior, they incur a loss of real and immediate satisfaction in exchange for the promise of a distant reward. The sober alcoholic, for example, must endure moment to moment the deprivation of alcohol’s comfort while waiting for the slow return of his employer’s trust or the gradual thawing of icy human relationships. It is the exchange of real and palpable comfort for only the promise of a better tomorrow that explains how frequently abstinence, whether from alcohol intake, procrastination, prevarication, satyromania, or other addictive behaviors so often gives way to renewed use.

Implications for Psychotherapy

The observations about normality, non-normality, psychopathology, and psychopathology-as-addiction have direct implications for the way Mowrer composed the treatment of psychopathology.

1. Negative emotions (fear, anxiety, worry, and guilt) are not per se the enemies of psychological health or the measure of the presence and severity of psycho-pathology. It follows that psychotherapy is not direct...

Table of contents

• Cover Page
• Half Title page
• Title Page
• Copyright Page
• Contents
• Acknowledgments
• Introduction
• Part I The Therapeutic Process
• Part II The Nature of the Problem
• Postscript
• Appendix
• Bibliography
• Index