Reality Therapy, Multimodal Therapy

Reality therapy was developed by William Glasser, a psychiatrist who was trained in (but later rejected) the concepts of psychoanalysis and views of behavior developed by Freud, Sigmund. Glasser holds the view that people who are behaving in inappropriate ways do not need help to find a defense for their behavior. Instead, they need help to acknowledge their behavior as being inappropriate and then to learn how to act in a more logical and productive manner. The bare bones of Glasser's theory are that people are required to live in a world full of other human beings, and every individual must learn to satisfy his own needs in a way that does not encroach upon on another person's needs.
Present reality therapy theory is based on the concept that our brain works as a control system. Therefore, if the brain is a control system, then all of our behavior is to fulfill needs built into the genetic structure of that system. This means that we, as well as all living organisms, spend our lives attempting to act upon, or more accurately, to control the world around us to fulfill powerful needs built into our structure. Therefore, we are not only completely internally motivated in contrast to the concepts of most psychological systems which are some variation of externally motivated behaviorism, but all of our behavior is for the purpose of fulfilling needs built into the system. Reality therapy attempts to help people control the world around them more effectively so that they are better able to satisfy their needs. 
The basic premises of Reality Therapy are as follows: 
•	Focus on the present and avoid discussing the past. 
•	Encourage people to judge their actions by "Is what I am doing getting me closer to what I need?" 
•	Help people create specific, workable plans to succeed in fulfilling their needs, and then follow through by helping them evaluate their progress.
Glasser draws on the teachings W. Edwards Deming in regard to his Quality School system. Deming taught the Japanese how to redesign their factories in their democratic society after World War II. Glasser equates our traditional school system to the failed factory model and calls on schools and teachers to apply Deming's principles of Quality Systems to classroom practices and Quality Schools.

Example of an individual seeking therapy from a Reality Therapist and treatment strategy.

	Joan contacted the therapist for what she described as depression following her recent divorce and subsequent custody fight over her 2 yr old daughter. Following the initial discussions about ethical issues related to treatment and a summary of what she can expect from reality therapy she gave the following history with little prompting. She married her high school sweetheart following graduation from high school. John was the first person she dated and she was two months pregnant when they married. She expressed some embarrassment over this and described her father as being furious with them at the time.  John worked nights and on weekends, spending up to two weeks away from home at least every other month. Following the birth of their child, she described feeling more and more lonely and cut off from her husband and others. She loved caring for her child, but her sex life with her husband diminished even more following the birth. At times they would go a month or more without having sex.  She said he would initiate sex more often than she, but she would say she wasn’t feeling well. She explained that she told him that she did not feel as if she knew him any more. 
	She described feeling overwhelmed, lonely, and detached from others.  She said she began to focus more and more on staying at home with her child, even putting shopping for groceries off until the very last minute, and then only to get milk for the baby. She has lost a good deal of weight and her personal appearance has suffered.  Her arguments with John were often over her lack of attention to anything except the care of the baby. The overall appearance of the inside of the home deteriorated from general neglect. Only the child’s room has remained neat and clean.  She has almost stopped seeing her parents, who live out of state and whose health condition has prohibited their visiting more than twice since the birth of the baby.  His parents are deceased.  Her only sibling also lives out of state. They talk on the phone occasionally, but her sister’s demanding job has limited much contact with her.  Joan’s circle of friends from school enrolled in college in another town and she only occasionally hears from them. She states that when she got married, everyone knew she ‘had to get married’ and that she is ashamed when she sees her friends in town. When she does see them at a store, she states she puts her shades on and tries to avoid them. If they call her when they are in town, she makes excuses not to see them and has not let them come over to see the baby, citing the baby being ill at the time.
	Most of Joan’s needs of belonging, power, fun, and freedom are clearly not being met.  She has little or no sense of belonging to others. Her feelings of shame and guilt prevent her contacting old school mates. She describes feelings and behaviors that evidence powerlessness over her environment. She rarely goes outside even to shop for groceries and essentials. The only activities she expresses any interest or animation about are those involved in caring or playing with her child.  She seems tied solely to her relationship with her child and lacks the freedom to engage in outside supportive relationships with other adults.  Her choices seem limited to her.
	Therapy will include discussing with Joan what she wants out of her life now and trying to help her focus on the present and near future. Her presenting problem, depression, will be discussed in terms of how she feels it affects her. She will be asked to consider how things might be if she was not depressed and to imagine what her life would be like if she was happy and had all her wants and needs met. The following discussion would use this information to develop a current list of specific wants for Joan.  These would be reflected back to her and revised until she was satisfied that these wants were what she felt accurately described her longings and would meet her needs. This would lead to a discussion on how her current behaviors were meeting or not meeting these wants and how she would like to see her behaviors changed.  A discussion would be developed that would elicit her affirmative commitment to changing behaviors.  Her actual behaviors, such as getting up late, going to bed early, spending too much time in bed, crying for hours at a time, watching television too much during the day, and other behaviors she connects to depression, would be explored in terms of how they relate to meeting her wants or not meeting her wants. Also, the therapist will elicit and suggest other possible depression related behaviors to add to this list.  
	What she is currently doing will be addressed. She will be asked to evaluate each of her behaviors in terms of how effective they are. Agreed upon assignments for specific behavior changes will be reached during therapy. These behaviors would be discussed to clarify how they would support or meet the wants Joan describes and how her life would benefit from them.  As she adds or alters behaviors she will be asked to evaluate the changed behaviors and her subsequent altered feelings in light of how her wants are being met and where she feels her behaviors are taking her.  A routine examination or reflection process will be mutually agreed upon where Joan is to regularly consider how her behaviors relate to the overall goals she has set for herself and if these goals are still viable for meeting her wants.  The therapist will reflect Joan’s wants back to her on a regular basis to determine shifts in perception on Joan’s part, assisting her in viewing her behaviors from a distance and from a critical perspective in determining if they are helpful or harmful. She will be asked if she were to review her behaviors objectively, what would she imagine the behavior’s goal to be. The therapist would help Joan look more closely at the goals she wants versus the goals that her current behaviors seem to be defining for herself.
	With assistance from the therapist she would develop a plan for incorporating behaviors into her life that would better meet her needs and to develop a pattern of personal feedback that would continually remind her of how well her behaviors are achieving this goal.  The plan would be clarified with Joan to ensure that new and current behavior goals contain the elements of being simple, attainable, measurable, immediate, and committed to.

Arnold A. Lazarus earned a PhD in clinical psychology from the University of the Witwatersrand, Johannesburg, South Africa; after 6 years as a private practitioner, he immigrated to the United States. He has taught at Stanford University, Temple University Medical School, Yale University, and Rutgers University where he has held the rank of distinguished professor of psychology since 1972. Lazarus teaches in the Graduate School of Applied and Professional Psychology and has a private practice in Princeton, New Jersey. 

The multimodal approach rests on the assumption that unless seven discrete but interactive modalities are assessed, treatment is likely to overlook significant concerns. Initial interviews and the use of a Multimodal Life History Inventory (Lazarus & Lazarus, 1991) provide an initial overview of a client's significant Behaviors, Affective responses, Sensory reactions, Images, Cognitions, Interpersonal relationships, and the need for Drugs and other biological interventions.

Example of an individual seeking treatment from Arnold Lazarus, using assessment and intervention with the 7 modalities summarized by the acronym BASIC I.D.

	Mary presented the following concern for treatment of what she described as depression over her inability to relate well to men while dating.  Though she dates men frequently and states that she generally seems to have an enjoyable time, she describes feelings of panic that occur during her dates, specifically when her date holds her closely, even during dancing.  
	Her modality profile reflects the following:
Behavior: Generally outgoing in most relationships, but markedly stand-offish if confronted with being held physically.
Affect: False levity or humor at these times.
Sensation: Feelings of cold with sweating and flushing.
Imagery: Of being smothered or trapped in a small space.
Cognition: Thinking, “I must be in control to protect self.”
Interpersonal: Avoidance of relationships that may deepen into more physical encounters.
Drugs/Biologicals: None
	In therapy she describes breaking out in a cold sweat, trembling, having a tremulous voice, heightened breathing rate, a rapid pulse, and flushing as occurring at the same time or shortly after even the most innocent embrace.  During therapy Mary is asked to detail what happens. She describes that this has become a repetitive ordeal for her and explains that she seems to follow a consistent pattern. She is usually having a good time with her date, enjoying either conversation, jogging, shopping, swimming, or even dancing (only apart, not close dancing), and each time she feels he might put his arms around her in a closed embrace, she gets this mental image (I - Image) of being smothered with a pillow or being pushed under a bed or into a closed space.  When she tries to put this out of her mind, she immediately begins to think (C - Cognition) about losing control. Sometimes this is a sense that he might force himself on her and at other times it is that she may not be able to stop herself from engaging in heavy petting or encouraging sexual intercourse.  At times she feels she would enjoy this escalation to further physical activity, but even when she thinks she would, she cannot deal with the fear of loss of control that she has during these moments.  She says that it seems the more she tries to gain control of her thinking the less control she has. 
	Her concern about control continues to escalate and she begins to feel flushed (S - Sensation) and she begins to sweat copiously.  She then feels herself stiffen (B - Behavior) and starts to pull away.  When she tries to retain some sense of normalcy or at least avoid offending her date, she begins to tremble. To cover this she laughs loudly or tries to make a joke of it (A - Affect). Her dates often get mad and call her a tease.  She says that most of the time she and her date continue to have a good time, especially if her date has a good sense of humor, as he often laughs with her. Her dates often express or exhibit obvious confusion over her affect and behaviors.  This often leads to the ending of the relationship as a close one (I. - Interpersonal), producing for her a string of acquaintances with no relationship progressing to physical intimacy. She finds this distressing as she has been really attracted to several of her dates, but she cannot seem to tolerate letting the relationship progress physically.  She does not take any drugs other than aspirin or medication for seasonal allergies. (D - Drugs/Biologicals).
	In therapy, her sequence is defined as I C S B A I., (Image, Cognition, Sensation, Behavior, Affect, and Interpersonal), reflecting the order in which she processes information. Imagery comes first for her, with a mental picture of her being smothered, and followed by her thoughts of becoming out of control, Cognition. This leads to the sensations of cold sweats and flushing, followed by distancing behaviors. These she tries to minimize by laughing and appearing funny or happy, altering her affect. This sequence is repeated and leads to behaviors that often stall a desired relationship and they become ‘just friends’.  
	Treatment would include a plan that gives Mary a sequence of activities and thinking processes that would mirror the same order, I C S B A I.  This sequence would deal first with her imagery.  She would be given other possible coping images to accompany and eventually replace the one of being smothered with a pillow. An alternative vision may be introduced that breaks the power of the pillow or diffuses the pillow’s negative image, or Mary may be encouraged to modify the pillow image to one that she is better able to deal with, such as a smaller pillow or one with few feathers. At the same time she would practice behaviors that would initially maximize her sense of control during embracing activities, perhaps with a friend or a doll. The therapist could use guided imagery to help Mary practice surviving embracing with incrementally less control issues until the act of embracing lost some of it’s power over her thinking, and reduced its tie to her vision and association with control.  These two sequences would be practiced in therapy, her new imagery followed by her new thinking about the control issue related to physical embraces.  Then using guided imagery, the therapist would work on better defining the sensations she is experiencing and encourage her to try experiencing these same feelings in other ways.  Through therapist or self guided imagery she would be asked to practice increasing and decreasing these sensations until she gains some sense of control of them by manipulating her thoughts in other areas. 
	She would practice suggested new behaviors to supplant her stiffness and pulling away, possibly engaging her date in the process.  Initially she may be given a specific time and method by which to ‘test’ her ability to withstand an embrace and limit embraces only to that specific situation in order for her to feel safer. By explaining her feelings and encouraging her date to provide feedback on her new behaviors, she may be better able to incrementally increase her time in an embrace.  Also, by engaging her date in her therapeutic trials, she would avoid some of her perceived need for her false affect in the relationship that she was using to cover her nervousness and embarrassment for pulling away from her date. Hopefully this will reduce her apprehension in deepening relationships and consequently help her decrease her avoidance behaviors that have prevented her from deepening her relationships with her dates.  
	The therapist would cover this sequence with Mary and help her practice the application of these new behaviors through guided imagery. During subsequent sessions, information on how she is doing in her attempts on refocusing, rethinking, and altering behaviors would be discussed.  Her images, behavior, and cognitive processes would be regularly revisited for changes that would benefit Mary.  

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