Reality Therapy

William Glasser, M.D.

• Publisher: HarperCollins e-books
• Year: 2010
• ISBN:
  9780062046925
• Topic: Psychology
• Subtopic: Cognitive Psychology & Cognition
• Index: Psychology

Glasser's classic bestseller, with more than 500, 000 copies sold, examines his alternative to Freudian psychoanalytic procedures, explains the procedure, contrasts it to conventional treatment, and describes different individual cases in which it was successful.

Part I

THEORY

Introduction

Reality Therapy is an effective psychiatric treatment different from that generally accepted today. Based on psychiatric theory which also differs greatly from conventional or traditional psychiatry, it is applicable to all people with psychiatric problems. This book will describe Reality Therapy, explain in detail how it differs from conventional psychiatry, and show its successful application to the treatment of juvenile delinquents, chronic mental hospital patients, private psychiatric patients, and disturbed children in the school classroom.

The first part of the book explains the basic concepts of Reality Therapy, a treatment applicable to both groups and individuals with psychiatric problems. Before we can understand treatment, however, we must have some idea of what it is that psychiatrists treat—what is wrong with the many people who seek psychiatric help. After the essential problem of all those who need psychiatric treatment is made clear, the development of Reality Therapy as a logical method of treatment is presented.

1

The Basic Concepts of Reality Therapy

WHAT IS WRONG WITH THOSE WHO NEED PSYCHIATRIC TREATMENT?

What is it that psychiatrists attempt to treat? What is wrong with the man in a mental hospital who claims he is Jesus, with the boy in and out of reform schools who has stolen thirty-eight cars, the woman who has continual crippling migraine headaches, the child who refuses to learn in school and disrupts the class with temper outbursts, the man who must lose a promotion because be is afraid to fly, and the bus driver who suddenly goes berserk and drives his bus load of people fifty miles from its destination in a careening danger-filled ride?

Do these widely different behaviors indicate different psychiatric problems requiring a variety of explanations, or are they manifestations of one underlying difficulty? We believe that, regardless of how he expresses his problem, everyone who needs psychiatric treatment suffers from one basic inadequacy: he is unable to fulfill his essential needs. The severity of the symptom reflects the degree to which the individual is unable to fulfill his needs. No one can explain exactly why one person expresses his problem with a stomach ulcer while another fears to enter an elevator; but whatever the symptom, it disappears when the person’s needs are successfully fulfilled.

Further, we must understand that not only is the psychiatric problem a manifestation of a person’s inability to fulfill his needs, but no matter how irrational or inadequate his behavior may seem to us, it has meaning and validity to him. The best he can do in an uncomfortable, often miserable condition, his behavior is his attempt to solve his particular variety of the basic problem of all psychiatric patients, the inability to fulfill his needs.

In their unsuccessful effort to fulfill their needs, no matter what behavior they choose, all patients have a common characteristic: they all deny the reality of the world around them. Some break the law, denying the rules of society; some claim their neighbors are plotting against them, denying the improbability of such behavior. Some are afraid of crowded places, close quarters, airplanes, or elevators, yet they freely admit the irrationality of their fears. Millions drink to blot out the inadequacy they feel but that need not exist if they could learn to be different; and far too many people choose suicide rather than face the reality that they could solve their problems by more responsible behavior. Whether it is a partial denial or the total blotting out of all reality of the chronic backward patient in the state hospital, the denial of some or all of reality is common to all patients. Therapy will be successful when they are able to give up denying the world and recognize that reality not only exists but that they must fulfill their needs within its framework.

A therapy that leads all patients toward reality, toward grappling successfully with the tangible and intangible aspects of the real world, might accurately be called a therapy toward reality, or simply Reality Therapy.

As mentioned above, it is not enough to help a patient face reality; he must also learn to fulfill his needs. Previously when he attempted to fulfill his needs in the real world, he was unsuccessful. He began to deny the real world and to try to fulfill his needs as if some aspects of the world did not exist or in defiance of then-existence. A psychotic patient who lives in a world of his own and a delinquent boy who repeatedly breaks the law are common examples of these two conditions. Even a man with a stomach ulcer who seems to be facing reality in every way is upon investigation often found to be attempting more than he can cope with, and his ulcer is his body’s reaction to the excess stress. Therefore, to do Reality Therapy the therapist must not only be able to help the patient accept the real world, but he must then further help him fulfill his needs in the real world so that he will have no inclination in the future to deny its existence.

HOW DO WE FULFILL OUR NEEDS?

Before discussing the basic needs themselves, we must clarify the process through which they are fulfilled. Briefly, we must be involved with other people, one at the very minimum, but hopefully many more than one. At all times in our lives we must have at least one person who cares about us and whom we care for ourselves. If we do not have this essential person, we will not be able to fulfill our basic needs. Although the person usually is in some direct relationship with us as a mother is to a child or a teacher is to a pupil, he need not be that close as long as we have a strong feeling of his existence and he, no matter how distant, has an equally strong feeling of our existence. One characteristic is essential in the other person: he must be in touch with reality himself and able to fulfill his own needs within the world. A man marooned on a desert isle or confined in a solitary cell may be able to fulfill his needs enough to survive if he knows that someone he cares for cares about him and his condition. If the prisoner or castaway loses the conviction that this essential human cares about what is happening to him, he will begin to lose touch with reality, his needs will be more and more unfulfilled, and he may die or become insane.

A graphic example in which two people sustained each other through severe hardship followed a recent airplane crash in the snowy wilds of northern Canada. A young woman and an experienced pilot lived forty-nine days without food before they were rescued. Not only were they in remarkably good physical condition but they did not even describe their total experience as horrible. Both said that they sustained each other and had faith in ultimate rescue. Although they were involved with each other through the circumstances, both were also involved enough with others so that they did not give up. They survived by not losing touch with reality and fulfilling their needs as well as they could.

Without the key person through whom we gain the strength and encouragement to cope with reality, we try desperately in many unrealistic ways to fulfill our needs. In doing so our efforts range throughout the whole gamut of psychiatric problems from mild anxiety to complete denial of reality. Therefore, essential to fulfillment of our needs is a person, preferably a group of people, with whom we are emotionally involved from the time we are born to the time we die. Much of what we call senility or senile psychosis is nothing more than the reaction of aged people to isolation. They may be physically near many people but no one is any longer involved with them. A beautifully written example is the play The Silver Whistle in which a young ne’er-do-well disguises himself as an old man in order to get into what he thinks is the warmth and comfort of an old folks’ home. Here he finds the occupants unnecessarily decrepit and senile. By helping them to become involved with each other he restores them to functioning much better than they had dreamed possible. Having had a similar experience working with a ninety-five-year-old patient, I can testify to the almost miraculous effect of getting a very old man involved in life again after he had thought it impossible. From a weak, bedridden, senile man he became a vigorous, self-sufficient, active member of the sanitarium patient group, all in a period of a little over three months.

Unless a patient becomes actively involved with at least one person in a better way than he is now involved with anyone, he will be unable to fulfill his needs. Well-meaning advice always fails—patients can’t straighten up and fly right when someone points out reality to them when there is not sufficient involvement. Without it no one can be helped to help himself fulfill his needs.

THE BASIC NEEDS

Now that we have seen that an involvement with someone you care for and who you are convinced cares for you is the key to fulfilling the basic needs, we can proceed to a discussion of the needs themselves. For therapy we recognize two basic needs—needs which cause suffering unless they are fulfilled.

It is generally accepted that all humans have the same physiological and psychological needs. Competent people may describe or label these needs differently, but no one seriously disputes that in all cultures and in all degrees of civilization men have the same essential needs. It is also generally accepted that needs do not vary with age, sex, or race. A Chinese infant girl has the same needs as a Swedish king. The fulfillment of the physiological needs for food, warmth, and rest are rarely the concern of psychiatry. Psychiatry must be concerned with two basic psychological needs: the need to love and be loved and the need to feel that we are worthwhile to ourselves and to others. Helping patients fulfill these two needs is the basis of Reality Therapy.

Although men of all societies, classes, colors, creeds, and intellectual capacity have the same needs, they vary remarkably in their ability to fulfill them. In every area of the world, including the most economically and culturally advanced, there are many people whose psychological needs are not satisfied, who are unable to give and receive love and who have no feeling of worth either to themselves or to others. These people are the concern of psychiatry, either because they directly present themselves for help, or because their behavior leads their family or the community to compel them to seek out-patient help or be placed in a psychiatric or correctional institution.

The proper role of psychiatry will always be to help people help themselves to fulfill their needs, given a reasonable opportunity to do so. Thus, a person with family and friends who care about him and with the opportunity to work in a reasonable job, who cannot fulfill his needs is considered to have a psychiatric problem. If, however, no one cares about him and he can obtain no gainful work, the problem may be more environmental than psychiatric. For example, if a Negro student at a newly integrated southern college is unable to study effectively, he is not necessarily suffering from psychological problems. If a potentially capable white student from a loving family flunks out of the same college, however, psychological guidance is more likely needed.

To develop the underlying problem—we all have the same needs but we vary in our ability to fulfill them—we must examine the generally accepted psychological needs in more detail.

First is the need to love and be loved. In all its forms, ranging from friendship through mother love, family love, and conjugal love, this need drives us to continuous activity in search of satisfaction. From birth to old age we need to love and be loved. Throughout our lives, our health and our happiness will depend upon our ability to do so. To either love or to allow ourselves to be loved is not enough; we must do both. When we cannot satisfy our total need for love, we will without fail suffer and react with many familiar psychological symptoms, from mild discomfort through anxiety and depression to complete withdrawal from the world around us.

Equal in importance to the need for love is the need to feel that we are worthwhile both to ourselves and to others. Although the two needs are separate, a person who loves and is loved will usually feel that he is a worthwhile person, and one who is worthwhile is usually someone who is loved and who can give love in return. While this is usually the case, it is not always so. For example, although an overindulged child may receive an abundance of love, the parents do not make the critical distinction between loving him and accepting his behavior, good or bad. Certainly the child should be loved, but love need not mean a blanket approval of everything he does. The child knows the difference between right and wrong behavior and is frustrated because receiving love for behavior that he knows is wrong does not allow him to feel worthwhile. In this situation, he reacts in all the familiar spoiled-child patterns in an effort to get his parents to enforce some behavioral limits and some achievement standards along with their love. When the parents do so, the child’s behavior improves. A beautiful and capable woman often finds herself in a similarly uncomfortable position when she is recognized only for her beauty. Therefore, an important part of fulfilling our need to be worthwhile depends upon the ability to see that being the object of someone’s love does not in itself give us worth.

But, whether we are loved or not, to be worthwhile we must maintain a satisfactory standard of behavior. To do so we must learn to correct ourselves when we do wrong and to credit ourselves when we do right. If we do not evaluate our own behavior, or having evaluated it, we do not act to improve our conduct where it is below our standards, we will not fulfill our need to be worthwhile and we will suffer as acutely as when we fail to love or be loved. Morals, standards, values, or right and wrong behavior are all intimately related to the fulfillment of our need for self-worth and, as will be explained later, a necessary part of Reality Therapy.

Thus, when we are unable to fulfill one or both of our needs, we feel pain or discomfort in some form. The pain, which may show itself throughout the whole central nervous system from a simple spinal reflex to our highest centers of abstract thought, motivates us to some activity to try to relieve it. If we sit on a hot radiator, we leap up to avoid burning ourselves. Similarly, but not as dramatically, if we are unable to love, we may shun people to avoid the pain of being in contact with those we cannot admit to ourselves that we need because we are afraid of rejection. Trying to tell ourselves that we do not need other people, we are like the fox who momentarily feels less pain when she walks away muttering, “Sour grapes.” Aesop did not reveal whether or not the fox consulted a psychiatrist for her denial of reality, but when a sour-grapes person who is unable to love removes himself from society, few would deny that he has a psychiatric problem. The problem is caused by his inability to behave so that he can give and receive love. He must become motivated to change his behavior because as long as he shuns people, he will continue to suffer. The only means by which we feel he can become motivated to change is to look honestly at his own behavior to determine whether or not it contributes to fulfilling his needs. Unless he can give up the sour-grapes attitude, face reality, and admit to himself that the grapes are probably sweet and that he must try harder to reach them, he will never fulfill his needs.

Learning to fulfill our needs must begin early in infancy and continue all our lives. If we fail to learn we will suffer, and this suffering always drives us to try unrealistic means to fulfill our needs. A person who does not learn as a little child to give and receive love may spend the rest of his life unsuccessfully trying to love. A woman, for example, may become involved in series of unhappy romances in which she uses sex in an unrealistic attempt to gain and give love. Only when she learns that there are better ways to attain love will she give up her unhappy, unsatisfactory behavior. A related example is a happily married woman whose husband dies. If she cannot adjust to her loss realistically and fulfill her need for love, she may follow the course of the woman in the previous example.

From the discussion we can draw an important conclusion. If we do not learn to fulfill our needs, we will suffer all of our lives; the younger and the more thoroughly we learn, the more satisfactory our lives will be. However, even if we learn at a young age to fulfill our needs moderately well, we may not be able to continue to do so all of our lives. From time to time in everyone’s life the world and our situation in it changes, requiring us to learn and relearn to fulfill our needs under different conditions and stresses. Whether we learn to fulfill our needs when we are young or at any time later, we must stay involved with people. Perhaps at first it is mother and father, then friends, teachers, lover, husband or wife, children, and grandchildren, but there must always be someone with whom we feel intimately involved. If at any time in our lives the involvement is broken, we will very quickly become unable to satisfy our needs. We might say, therefore, that all people who have any kind of serious psychiatric problem are at that time lacking the proper involvement with someone—and, lacking that involvement, are unable to satisfy their needs.

We know, therefore, that at the time any person comes for psychiatric help he is lacking the most critical factor for fulfilling his needs, a person whom he genuinely cares about and who he feels genuinely cares about him. Sometimes it is obvious that the patient has no close relationships. Many times, however, especially in patients who are functioning fairly well and come to a psychiatrist in private practice, the lack of involvement is not apparent. Patients may have devoted wives, friends, and family, but they still are unable to fulfill their needs. Despite the presence of people who claim they care, the patient is either not able to accept their love, or he does not care for them. What appear to be satisfactory relationships are not satisfactory for him, a condition often graphically illustrated by the case of many suicides. A person who commits suicide may have many people who care about him and he may be successful in his work, yet still leave a note describing the overwhelming loneliness and isolation he feels. Therefore, to obtain help in therapy the patient must gain or regain involvement, first with the therapist and then with others. His problem and the accompanying symptoms will disappear once he is able to become involved and fulfill his needs.

Fulfilling his needs, however, is a part of his present life; it has nothing to do with his past no matter how miserable his previous life has been. It is not only possible, it is desirable to ignore his past and work in the present because, contrary to almost universal belief, nothing which happened in his past, no matter how it may have affected him then or now, will make any difference once he learns to fulfill his needs at the present time.

Having established that we are concerned with involvement and what the patient is doing now in contrast to the usual emphasis on his past life, we must also state that we do not concern ourselves with unconscious mental processes. We do not deny that they exist as demonstrated vividly by our...