CAMFT's Professional Exchange

Counseling with Choice Theory:
A New Mental Health Model

by: William Glasser, M.D.

(January/February 2005 The Therapist)

By replacing the medical model with the mental health model, I have significantly helped almost every client I have worked with using the reality therapy I began to develop in 1962. Beginning in 1979, I expanded this therapy and increased its effectiveness by adding what I now call choice theory to my counseling. In 1998, I published the basic book, Choice Theory. The material in that book is the guide for the way I conduct both my personal and professional life. I will describe my counseling as much as I can in this short article, but to get a feel for the whole process, I suggest you read my 2001 book, Counseling with Choice Theory, the New Reality Therapy.

Even though I have been a psychiatrist for almost fifty years, I have restricted my practice to counseling and psychotherapy. I reject the medical model because the people I have counseled are no more mentally ill than a couch potato is physically ill. I see them as less than mentally healthy as a couch potato is less than physically healthy. When I counsel, I teach clients to improve their own mental health. I do that by talking with them and getting to know them because in my experience, they want to talk with me as much as I want to talk with them.

The warm supportive relationship we create by talking and listening leads clients to be receptive to learning how they can improve their own mental health. As we work toward that goal they become happier and begin to lead a quality life. Because of what I believe, I have never told a client that he or she is mentally ill. That's hardly the way to start a warm, supportive relationship. It goes without saying that I have never diagnosed a DSM-IV mental illness (except insurance payments), or prescribed a psychiatric drug.

To begin, I have to say that the DSM-IV is accurate to some extent when it describes some typical psychological symptoms. But, too often, it describes many to the point of absurdity. For example, the DSM-IV identifies the normal fidgeting of young children as evidence of pathology in their brains. Fidgeting or not paying attention is almost never evidence of brain damage. But the DSM-IV is totally inaccurate when it takes a further step and claims that all psychological symptoms are the result of a mental illness or a disorder caused by pathology in the brain. The best explanation of why both the DSMIV and the medical model are inaccurate, misleading and harmful to the mental health of the people we counsel, can be found in Robert Whitaker's 2002 book, Mad in America. I believe everyone who counsels should read that book.

Citing reams of scientific evidence, Whitaker explains that no matter what the psychiatric establishment may claim, no legitimate research has shown there to be any pathology in the brains or brain chemistry of the people with the psychological symptoms described in the DSM-IV. I realize this claim may be hard to believe because we have been so heavily exposed to the claims of psychiatrists who support the medical model. Still, giving up this model and replacing it with the new mental health model should be easy for CAMFT members because you are already counseling your clients successfully without brain drugs.

Instead of even mentioning DSM-IV diagnoses, as soon as I begin to talk with clients, I tell them they are not mentally ill; there is nothing wrong with their brains or their brain chemistry. If you work for a clinic or group that closely follows the medical model you may have to omit this information from your counseling but you should have no problem with the rest of this article. The next thing I do is explain that my counseling focuses on helping them to improve their own mental health.

If they ask me what mental health is, I explain it is the ability to get along well with the important people in their lives and we'll get into that right away when I ask them to answer a simple question. I tend to use either one or the other of the following two questions: what's happening, or can you tell me your story? I start this way because I don't even want to infer that the symptoms they may be prepared to tell me about will convince me they have a diagnosable DSMIV disease such as depression, anxiety attacks or bipolar disease.

If I started by asking clients about their symptoms, as in the medical model, they could infer that I believe they have a mental illness and that I, a professional, can help them to get rid of the symptoms I have just asked about. They think this way because the only model they know when they go to a professional for help is the medical model. They expect the doctor to ask about their symptoms, diagnose a disease and write a prescription.

When I ask them "what's happening" or "can you tell me the story," they feel better. They want to tell me what is on their minds. They have no trouble answering these questions because everyone who comes to me has a story and is anxious to tell it to me. To counsel successfully, the relationship between the client and counselor is very important. These questions tell them I'm interested in their story which means I'm interested in them and that interest helps get the counseling started. In the rare instance where they may be reluctant to tell me their story, I encourage them by saying their story is very important and I have plenty of time to listen to it. For many of them hearing a doctor say he or she has plenty of time is a new experience.

When they start to talk, I look for how they are getting along with one or more of the important people in their lives. Mostly they will tell me that they are not getting along as well as they would like with their spouse, children, parents or other family members. At times it may be a friend, a lover, a teacher or an employer. It is always someone important, and in most instances, as the story progresses, they also tell me it's not their fault but the fault of the other person. "Everything would be fine if he or she would treat me better."

Then they ask me if there is anything I can do to change the way the other person is treating them. When we get to that point (and it is often in the very first session of the counseling), I begin to explain choice theory and how learning to put choice theory to work in their lives will become the heart and soul of the way I counsel. Using many examples, I will teach them that the only person's behavior I can help them change is their own.

This then leads to an important discussion. They ask why it is that I can only help them to change the way they behave. Why can't I help them to change the other person's behavior? But as we continue to talk, I explain the basic choice theory concept that we can only control our own behaviors, that we can only live our own lives and that we can't live anyone else's life. As we talk I ask them if they have ever been successful in changing anyone who doesn't want to change and they begin to see my point.

It may come out that if they use enough pressure, other people will change what they may be doing, but only as long as the pressure is continued. Nothing has changed in what the other people are thinking and as soon as they reduce the pressure, the other people will go back to behaving the way they were. I also tell them that if they will start to behave in ways that improve the relationship, no matter what the other person is doing, it is possible that the other person will learn to change in the same way. For example, if there is a lot of criticizing going on and one person stops, the other may stop too. If this happens, the relationship will change for the better.

What I am offering is a drug- free, mentally healthy, counseling alternative to the multibillion dollar advertising campaign financed by the drug companies that is aimed at convincing both lay people and professionals alike that our society is inundated with mental illnesses caused by pathology in our brains. Take your medicine and you can reduce or eliminate your psychological symptoms and become happy and well adjusted.

There is not a shred of truth in this advertising. Selling potentially harmful brain drugs directly to the users so they ask their doctors to prescribe them is destroying the chance for millions of people to improve their own mental health. What our clients need is to learn something they don't know-how to put choice theory to work in their lives. I warn both the general public and the professionals who deal with them about this danger in my 2003 book, Warning, Psychiatry Can Be Hazardous to Your Mental Health.

As Whitaker explained in Mad in America, brain drugs all work by harming the brain. The psychiatrists and physicians who prescribe them tell their patients it is likely they will need these or other drugs for years on end. When you counsel with choice theory you can explain to your clients that the purpose of your counseling is to help them to improve their mental health and the quality of their lives without drugs. But to protect yourself you should tell any of your clients who may be on brain drugs or want to go on them that you will work with them whether they are on brain drugs or not. As their symptoms disappear, you can encourage them to talk to their prescribing physician about their drug needs.

But as I ask them the initial question and then focus on how they are getting along with the important people in their lives, it slowly becomes apparent to them that their underlying problem is they are involved in at least one very unhappy relationship. From there, I explain that choice theory is a psychology they can use to get along better with each other. As the counseling continues, they can begin to use it in the unhappy relationship and all of their other relationships. From the beginning I believe that the more they know about what I am doing, the more effective I will be.

As I explain choice theory, clients find it hard to believe that something so common to all our lives as unhappiness can be the real problem. I teach them that, while unhappiness is a very serious problem, there is nothing wrong with their brains and they are more than able to learn to help themselves. I explain that a perfectly normal brain can be a very unhappy brain. I accept completely that the symptoms they suffer from when they are unhappy are real and in many instances disabling. But being unhappy is not itself a symptom; it is a self-appraisal that all of us make all the time. At any moment in our lives we know if we are happy or not. If we don't know, we are much closer to happiness than to unhappiness.

What they learn from my counseling is not only how to get along much better with the people they are not getting along with now, but also why so many of us don't get along well with each other. If they know why, they have a much greater incentive to make the effort to change. For example, millions of couples divorce each year but few of them know why they can no longer get along with the person who, in the beginning, they got along with so well. Choice theory teaches us that we are social creatures; the need to love and belong is encoded in our genes and when we can't satisfy it we are very unhappy. Choice theory also teaches that there are also three other needs survival, freedom and fun that are encoded in our genes. We also must find ways to satisfy these needs if we are to be happy. But I focus on the need to love and belong because to satisfy that need, we have to find another person to love us. That makes it more difficult to satisfy than the need to survive, find some freedom and enjoy ourselves. For any relationship to last, both partners have to work at it together.

But what will come as a surprise to most readers of this article, as well as to almost all the people we counsel, is that we humans, have a fifth need- power-that is unique to us. This may be the last need encoded into our genes and probably came with the onset of civilization. The powerful survived in much larger numbers than those who lacked this motivation. Driven by this need all of us struggle to feel important, to be respected and to get the attention of others. As far as unsuccessful relationships are concerned, the worst is we are willing to harm, even kill people, who don't do what we want them to do. In all levels of any society, struggling with power causes the vast majority of human misery. Learning as much as we can about power and how we can satisfy it becomes a very important part of counseling with choice theory.

As you continue to counsel, it is important to explain to your clients that the desire to satisfy their needs is encoded in their genes but, in humans, the behaviors to satisfy them are all learned. We may get very hungry, very lonely, lead a life lacking in fun and feel very unimportant. But how to find food, find a friend, find some fun and find the respect we need if we are to satisfy our need for power, we must learn better ways than most of us know now. I teach these ways as I counsel.

The most difficult need to satisfy is power and the only way we can satisfy it and still get along well with each other is to learn to respect as many people as we can. Further, we need to learn to behave in ways so that others respect us. All this is explained in Choice Theory and, re-explained in most of my other recent books. Referring my clients to these books so that they know more about how to improve their own mental health is a very important part of the way I counsel.

Perhaps the most important component of choice theory is to learn why it is that so many of us behave in ways that harm or destroy our relationships. Because this will come up over and over in your counseling, I have grouped together seven behaviors we have all learned no matter what part of the earth we come from and I call them the seven deadly habits that destroy all relationships. They are criticizing, blaming, complaining, nagging, threatening, punishing and bribing or rewarding to control. I teach my clients to replace these with the seven caring habits: supporting, encouraging, listening, accepting, trusting, respecting and negotiating. If your clients can do this, they are well on the way to quality life.

These behaviors are integral to what choice theory explains is a world psychology that destroys relationships in every human society. The name I have given to this psychology is external control. I use the term, psychology, because I believe it is an accurate way to describe how we tend to behave in a particular situation. In this case, the situation is the very common one of trying to get along well with each other. What makes external control so destructive to relationships is that when you put it to work in your life, you believe and often say, "I know what's right for you." Many people take it to the extreme and firmly believe that they know what's right for everyone. As I said earlier, but I can now explain, you are using external control when you can't get along with someone and take the position that what you are doing is right and it must be the other person's fault.

In an unhappy marriage, the least successful of all our relationships, husbands know what's right for their wives and wives know what's right for husbands. Based on this knowledge, they each try to change the other. As this continues and accelerates as it usually does, the marriage goes downhill and eventually will end whether they divorce or not.

In counseling, I teach that the most successful way to a mentally healthy or quality life is learning to replace the external control all our unhappy clients are using now with choice theory. If you meet a very happy person you will immediately notice that he/she doesn't try to change anyone. He/She has learned to live and let live. If people try to control him/her, he/she will have learned a variety of ways to escape that control.

I teach that people would be wise to try to put choice theory to work in their relationships. Much of parental or marital counseling will involve trying to teach clients to use choice theory. In the end, what they will learn from the counseling process is a different way or a choice theory way to live their lives. This may happen quickly or it may take a while but how long will be up to the skill of the counselor. The more skillful you become, the shorter it will take. You can gain this skill by putting choice theory to work in your own life. I don't believe you can successfully teach it to others if you haven't integrated it into your own life.

When I deal with couples, the first thing each partner wants to tell me is, "It isn't my fault." They want to make me the judge who declares them innocent. My job is to explain it doesn't make any difference whose fault it is because no matter what the other person does or doesn't do, one or both of them can put choice theory to work in the relationship if they want to improve it.

When either of them does, the relationship will become mentally healthier and both parties will benefit. If they both put choice theory to work, it happens more quickly.

In many instances, the people I counsel want to blame people they encountered in their childhood for what is wrong with their adult lives. They tell me about long ago mistreatment that they believe is still destroying their happiness. When they do, I tell them that I've never found this is to be the real problem. I explain that when they were mistreated they learned it wasn't safe to trust people and they have carried that mistrust for many years.

What I teach in counseling is to give the people in their present lives, people who haven't mistreated them, a chance to get close. Certainly they have to be careful and go slowly. I guide them in this process and I make sure I don't do or say anything that might cause them to mistrust me. This may take a while, and with couples, I may have to talk with them together and teach them both the choice theory that will eventually help them to trust the other. When they finally learn to trust, they are on their way to mental health.

It is also very common for people to want to talk at great length about their symptoms, how depressed they are or about the voices they hear that "must" be real. All I can do, and it takes patience to keep doing it, is keep explaining that the symptoms, no matter how severe, are not the problem. The underlying problem is the unhappiness. When they become mentally healthier, the symptoms will disappear.

Often clients try to control me with extreme symptoms in an attempt to divert my attention from the real problem: a present unsatisfying relationship. If you let your clients control you with their symptoms, you can't help them. When it gets to severe symptoms such as hallucinations, delusions or suicidal threats, counseling can become more complicated than I can explain in this article. There is, of course, much more choice theory to learn than what I can explain here.

Another situation that occasionally occurs is the client who has no satisfying relationships in his or her life. In this instance, the relationship with me has to become the satisfying relationship they need to get the counseling started. In these instances, the counseling may get very difficult, but I won't accept that I am the only one he/she can relate to. The real test is, can I teach such persons enough choice theory so that someone else will enjoy being with them? In these difficult situations, people sometimes ask whether there is another way- maybe a more powerful way-to counsel than with choice theory. I often wish there was but I have yet to find it. If you find it, please pass it along to me.

I look forward to seeing you at the Annual Conference in San Jose on May 15th. Come prepared to learn, laugh and challenge with role-plays. It will be fun to meet and work with you.

Dr. William Glasser is an internationally recognized psychiatrist who is best known as the author of Reality Therapy, a method of psychotherapy he created in 1963 and is now taught all over the world. In March of 2003, he was presented with the ACA Professional Development Award, which recognizes the significant contributions he has made to the field of counseling throughout his professional career.

PROFESSIONAL EXCHANGE: The articles printed under the heading “Professional Exchange” represent the views and opinions of the writers and do not necessarily reflect the attitudes or opinions of the California Association of Marriage and Family Therapists. Some articles are printed to stimulate thought, and in some cases, to arouse controversy. We print these articles so you may read what your colleagues and other professionals are doing and thinking. We realize that learning is enhanced when all sides of an issue are exposed, allowing each individual to develop his or her views. You may not agree with the views expressed, however, we hope that these articles will stimulate you to respond and share your expertise and experience with your peers. Please send your articles and comments to Editor, California Association of Marriage and Family Therapists, 7901 Raytheon Road, San Diego, CA 92111-1606.