Effectiveness of Reality Therapy
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Keywords: reality therapy interventions, reality therapy evaluation
Initially, control theory was foisted as the theoretical basis for reality therapy (Glasser, 1989). Overtime, however, it evolved and was renamed choice theory to emphasize the personal freedom people had to choose their behaviours to lead healthy lives and maintain loving relationships (Nelson-Jones, 2001). The core concepts and assumptions that inform choice theory are basic needs, quality world, and total behaviour.
Basic needs. Choice theory assumes that people are motivated by basic needs, which have a genetic origin. The five basic needs include 1) survival needs of self-preservation and meeting physical needs, 2) love and belonging needs of sustaining healthy relationships, 3) power needs of attaining a sense of self-worth through status and recognition from others, 4) freedom needs of independence and autonomy, and 5) fun needs of enjoyment which motivates learning. These five needs are thought to be equally important and can work in tandem or against each other (Austad, 2009). The task of satisfying needs is never-ending, as another need arises after one has been fulfilled. Pleasure follows a fulfillment of these needs and pain results from a failure to satisfy them. Accordingly, people try to maximize pleasure and minimize pain (Austad, 2009). As such, the choices that people make are behaviours which represent how people try to satisfy these basic needs (Nelson-Jones, 2001).
Quality world. The quality world is what Glasser (1998) refers to as the personal picture album. It contains mental snapshots of people, things, ideas, and systems of beliefs that a particular person perceives as being critical in satisfying his or her needs. Every person is supposed to have a different mental picture for each corresponding need. So while the basic needs that drive behaviour are universal (Wubbolding et al., 2004), the images, which represent the ways by which the needs are satisfied, are unique to each individual. The quality world pictures can be changed, though it is challenging and the pictures in the mental realm of others can only be accomplished through "negotiation and compromise" (Nelson-Jones, 2001). Choice theory sees the desire to reduce dissonance between the ideal quality world picture and the actual situation in reality as the motivation which engenders behaviours (Austad, 2009).
Total behaviour. Choice theory understands all behaviour as total behaviour comprising of four interlocked components: acting, thinking, feeling, and physiology. People are thought to be more aware of how they act and think but have less control over their feelings and physiology (Austad, 2009). Choice theory, however, proposes that everyone has control over their feelings and physiological responses, albeit indirect. The notion of total behaviour underscores how behaviour is a choice and its other components are also within a person's control. Additionally, Glasser expresses the feeling component through verbs (instead of adjectives), such as depressing, anxietying, and phobicking, under the choice theory framework by which active language further emphasizes how the behaviour is generated internally and it is within people's choice (Austad, 2001).
Ultimately, choice theory posits that the healthy person is one who chooses appropriate behaviours to fulfill his/her five basic needs. Similarly, abnormal behaviour, also by choice, signifies a failure in satisfying one's needs. Glasser (1998) disregards the psychiatric medical model of DSM diagnosis and argues that, apart from genetically based illnesses such as Alzheimer's, other abnormal behaviours stem from unhappiness, due largely to dysfunctional relationships. Choice theory suggests that, in an attempt to fulfil their own needs, people might want to control someone else but this inevitably disrupts their relationship. As such, the core assumptions of reality therapy and choice theory is that people can only truly control themselves, and can thus make choices on their behaviours to meet their needs.
Even though the concepts may seem simple as presented, being able to translate them into actual therapeutic practice takes considerable skill, creativity and flexibility on the therapist's part. The art of practicing reality therapy differs for different therapists, depending on their personal characteristics and interpretation style. (Corey, 2009) Generally, the therapist should engage the client in thinking about him or herself according to a four-stage method - wants, doing, evaluating and planning - which can be typified in the form of four main questions (Wubbolding, 1991).
The first is, "What do I want?" which denotes the wants stage. The notion of a quality world is driven by specific wants and needs, and as such, to fully understand and tend to the client's wants, the therapist should establish adequate involvement and a positive relationship with the client. According to Glasser and Zunin (1973), involvement is seen as the "primary intrinsic force governing all behaviour". It is associated with a genuine, caring and warm therapist-client bond (Turpin & Ososkie, 2004). A good relationship is crucial; without which, subsequent steps and strategies in therapy would not be effective. After the establishment of a warm relationship, the therapist can get the client to share what the main issue at hand is, and what his goals of therapy are. Questions can address goals as short-term such as "What do you want to take away when you leave today's session?". They can also address particular needs such as "Who, in your life, is the most important to you?" (belonging) and "What kinds of decisions are you reluctant in making?" (freedom).
The second is, "What am I currently doing?" which denotes the doing stage. A key concept in reality therapy is focus on the present, not on the past. Present perceptions influence an individual's current behaviour. As such, the therapist should strive to work on the present instead of dwelling on past events. Additionally, the therapist should get the client to focus on what he or she can directly do or change (such as how they act and think) instead of what cannot be done as easily (such as feelings and physiological reactions). The predominant matter of discussion is behaviour, as it is the area that can be most easily and effectively changed. When this component is successfully altered, thinking and feeling will follow suit as they are all interconnected (Wubbolding, 2000). Ineffective cognitions, such as "I have no choiceâ€¦ there is no other way", are also identified and worked on.
The third is, "Is it working?" which denotes the evaluating stage. This is the core of therapy. Here, the client is prompted to self-evaluate his or her actions, encouraging him or her to assess if current behaviours (today, yesterday, or in general) are either facilitating or hindering the attainment of the previously mentioned goals. Additionally, the therapist should get the client to consider the suitability and rationality of the wants and goals put forth, and to consider how far he or she is willing to go to attain them. Self-evaluation thus involves assessing the degree of willingness to work to bring about a positive change. Since reality therapy is largely focused on interpersonal relationships, the therapist should also get the client to consider the impact that his or her current actions have on the people around. According to Wubbolding (2000), many people are "incapable of making judgments on the basis of inner norms or even of perceiving the impact of their behaviour on others". Thus, the client should be prompted to appraise whether current actions might oppose any rules or expectations of the people around them.
When current behaviours are evaluated as inappropriate, the final question that can be raised is, "What else can I do?", which denotes the planning stage. Plans should not have the intention of directly curing or resolving problems; rather, they should serve to enhance and improve conditions. The therapist may suggest a plan of action, but it is more advantageous and effective if the client himself has input into the matter. It is highly crucial that plans be specific and very workable. The preliminary steps should not be too ambitious; the therapist should ensure that they are simple enough to guarantee that the client will succeed and therefore continue with subsequent stages of therapy with confidence.
It should be noted, however, that this 4-stage model of therapy is more cyclical than it is linear. The cycle repeats many times over several therapy sessions until the goals of the client and therapist are attained. As such, it is critical that the therapist continually evaluates the progress of the client. The client should be fully committed to the plans implemented and to therapy in general. The therapist should be non-accepting of excuses not to adhere to plans. Thus, a good therapist-client relationship may very well ensure in a "working alliance" (Grencavage & Norcross, 1990) which would indefinitely help in ensuring continuous commitment and involvement throughout therapy.
Current Applications of Reality Therapy and their Effectiveness
Owing to the interpersonal nature of reality therapy and the ubiquity of social situations, Glasser (1965) has outlined many uses of reality therapy in a variety of settings. In fact, the various William Glasser Institutes set up around the world teach reality therapy and choice theory in these applications, and has an international following, including here in Singapore. However, many of these applications, as with the concept of reality therapy itself, has a dearth of supporting literature.
There are, however, a few studies which quantitatively examine the efficacy of reality therapy in clinical, school, correctional and counseling settings. Sheryl (2006) examines a client with Post-Traumatic Stress Disorder (PTSD) and the effectiveness of reality therapy in symptom reduction. It was found that reality therapy intervention resulted in a 50% reduction in PTSD-linked somatization and rumination behaviors. It is notable that this case study approach is lacking in terms of control subjects, and thus requires additional research. It is also acknowledged that in a clinical setting, one of the requirements for successful application of reality therapy is that the patient must be able to adequately perceive and behave consistently according to reality. McMordie (1981) suggests that a psychotic patient, being "not in contact with reality" (p. 140), requires behavioral intervention first to bring the inappropriate behavior into consistency before a cognitive intervention of any nature. Thus we can deduce that the reality therapy is effective in clinical settings insofar as there is no significant cognitive impairment. It is also notable that Glasser (1965) himself acknowledges the limitations of reality therapy when dealing with organic disorders.
The most researched use of reality therapy to date appears to be in school settings. A study by Peterson, Chang and Collins (1998) showed that Taiwanese college students studying either choice theory or undergoing reality therapy were significantly more aware of control over their own behaviors, and actually practiced the techniques for changing than the control group. Loyd (2005) examined the perceived satisfaction of high school students on dimensions of psychological needs such as belonging, power, freedom and fun and its effect on behavior. It was found that students exposed to choice theory and reality therapy scored significantly higher on these psychological needs compared to control groups. Passaro, Moon, Wiest and Wong (2004) conducted reality therapy in an in-school support room, and found that students undergoing treatment were able to make better decisions, and able to self-initiate cognitive and behavioral change. These students were less likely to receive disciplinary actions as compared to students who did not undergo the treatment. Additional studies conducted on elementary school students in Korea (Kim, 2002) reinforce the efficacy and the universality of reality therapy and its applications in cross-cultural school settings, as well as across schooling ages.
Another application of reality therapy would be in group counseling settings. Group counseling based on reality therapy has been considered to aid in shifting clients from an external to an internal locus of control, as well as increase achievement motivation (Rose-Inza and Mi Gu, 2001). The group setting has been recommended by reality therapy proponents because of the safe haven provided in which inter-personal relationships can be formed (Glasser, 1965), and it is important to note that interpersonal relationships are fundamentally linked to the basic human problems as outlined by reality therapy and choice theory.
Although not extensively studied, reality therapy can also be applied in correctional settings. Rachin (1974) had suggested that clients in correctional institutes responded well to reality therapy, despite numerous failed attempts to reform using conventional treatment methods such as behavioral or medical approaches. Reeder (1997) found that the use of any therapy which had a prosocial action component (including other therapies such as Friendship Therapy) resulted in more prosocial behavior in prison immates. However, it was also suggested that since the prison setting itself does not promote the development and sustainment of such behavior, and may thus counteract any lasting positive effects of the therapy.
There are many more settings in which proponents suggest reality therapy may be applied, such as sports where goal-setting and achievement motivation is required for success (Edens, 1997). However, there is still much research required in this aspect of reality therapy, and many of these applications have yet to be rigorously researched and evaluated in order to complete the current dearth of data and literature.
Application of Reality Therapy's Concepts and Techniques in Future Settings
Since reality therapists believe the underlying problem of most clients is due to a present unsatisfying relationship or lack of a relationship, we suggest that reality therapy concepts and therapist techniques can be extended to other possible settings.
The practice of reality therapy assumes that a supportive and challenging environment allows clients to start making life changes. (Corey, 2009) While establishing a safe and secure atmosphere for clients in reality therapy is similar to the concept of rapport building in conventional therapies but the techniques that reality therapists use are unique.
Research on reality therapy has been conducted in settings such as schools and correctional institutions; and with specialized populations such as depressed clients, sexually abused clients and teachers. However, limited research exists on reality therapy applied to marriage and family counselling. We suggest that therapists can follow the 'Wants, Direction, Evaluation and Plans' (WDEP) system when working with couples and families. Therapists can help couples and families identify their common wants, behaviours, and perceptions as well as negotiate how to accept and live with the differences. For example, if the family has decided to stay intact and connected, therapists can help the family define what they want from one another and then proceed to make specific plans to achieve the goals. The WDEP system can be used with flexibility, depending on the client's circumstances. By helping the client to explore the specifics of his/her behaviour, they are in tune with the reality, the present world around them and see how their thoughts, feelings and actions are impacting their lives. Therefore, all therapists can use the WDEP formula to work with all types of clients with adequate cognitive level and insight to understand their behaviours and whether they are heading towards the overall direction that they desire in their life.
Secondly, self-evaluation is at the heart of reality therapy. The explicit inquiry about the effectiveness of their specific actions and their life direction helps them to pause, take stock of their lives, and examine how to make changes. Individuals will not change until they see the need for change. We suggest that asking clients who have addiction problems questions such as "Is what you are doing helping or hurting you?", will allow the clients to see the incongruence between their behaviour and the greater goals in life. Additionally, when the reality therapist asks an addict if the excessive behaviour they are engaging in presently helps them in the long run, the idea of choice is being introduced. Clients with alcohol problems will realise they cannot control others around them from not drinking, they cannot stop the media companies from showing advertisements on television, thus they can only control their own behaviour and they are not victims to the world around them.
Personal responsibility, a concept basic to reality therapy, is defined as the ability to fulfil one's needs, and to do so in a way that does not deprive others of the ability to fulfil their needs. Therapists can challenge their clients after establishing a safe and secure environment because all clients, in their unsuccessful efforts to fulfil their needs, share a common characteristic: They all deny the reality of the world around them. For example, clients who have attempted suicide did it to avoid facing their problems with a more responsible attitude and clients who express phobias of crowded places freely admit their irrational fears and are in partial denial about reality. (Glasser, 1965) In correctional settings, there may be offenders who do not take responsibility for their actions. They may have felt that they are being oppressed by the society and they are not given chances to be a meaningful person, thus they commit the criminal act. Such clients usually come to therapy to talk about what infavourable things others are doing to him/her. These subjects are easy as they excused one's failures and disregard one's personal responsibility towards the outcome. It is crucial for the therapist to spend adequate time listening to their past behaviours to convey the message of acceptance and more importantly, to focus on what the client is doing and thinking now. By empathetically guiding offenders to take responsibility for their own actions, these offenders will stop perceiving things through a negative worldview and start afresh by learning how to connect to others and living a more satisfying life.
Reality Therapy in Multi-Cultural Settings
According to William Glasser, reality therapy can be applied both individually and in groups to anyone with psychological problem in any cultural context. Although reality therapy assumes all humans have the same basic needs, the therapist must alter the style of delivering the therapy when working with culturally diverse clients. However, a shortcoming of this approach arises when working with clients who are discriminated on the basis of ethnicity and sex. Discrimination, racism and sexism are societal forces that operate against these clients in everyday life and may limit the choices that they have. Reality therapists who introduce the concept of choice strongly in the early stages of therapy may make the client feel misunderstood and result in them dropping out from treatment. Therefore, therapists should focus on the choices that these clients have and to address the issue of limited choice due to environmental constraints.
Additionally, successful reality therapy requires active input from the clients. When dealing with clients from cultures where clients may be more reluctant or shy to verbally express their needs or collectivistic cultures where clients are expected to place group needs above individual needs, the therapist may need to "soften" reality therapy and be more sensitive to the cultural norms.
In conclusion, the reality therapist seeks to become involved with the client and aid him/her to face reality together. With the strength from the therapist, the client is challenged to decide if he/she wishes to take responsibility for a better future. By teaching people that they have a choice in matters help to alleviate the helplessness and hopelessness they face.
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