A Universal System of Psychotherapy

Currently it is generally accepted that existing theories and approaches to psychotherapy, developed in Western cultures, are not applicable to other cultures. A model is proposed that, while based on certain theoretical and research foundations in Western culture, also recognizes and derives from universal drives, motivations and goals of all human beings, indeed of all living organisms. It is therefore neither time nor culture bound. The model is developed in terms of three levels of goals: (1) the ultimate goal, common to all clients; (2) mediate goals, that allow for cultural and individual differences; and (3) the immediate goal, involving the therapy relationship. The therapist conditions necessary, and possibly sufficient, for the development of a relationship leading to the achievement of the mediate and ultimate goals are defined. INTRODUCTION Over 20 years ago I began putting together what we know, from experience and experiment, about psychotherapy. I used the term "model" to describe the result. It is not a model in the formal or mathematical sense, but a conceptual model. It has gone by different names in the process of development as I realized that it is not limited to psychotherapy. It is actually a model for all facilitative interpersonal relationships-family (parent-child, husband-wife), teacher-student, employer-employee, supervisorsupervisee. Recently I have also come to realize that it is a universal model, in that it is not time-bound nor culture-bound. I am aware that to suggest that there is a universal system of psychotherapy flies in the face of almost everything that has been written about cross-cultural psychotherapy. Currently it is generally accepted that existing theories and approaches to psychotherapy, developed in the Western cultures, are not applicable to other cultures. The system developed here, while based on theoretical and research foundations in Western culture, also recognizes and derives from the universal motivation and goal of all human beings. There are three major elements of psychotherapy: (1) goals or objectives; (2) the process in the client; and (3) the therapist conditions necessary for client progress. GOALS There has been surprisingly little fundamental consideration of the goal or goals of psychotherapy. This is surprising in view of the tremendous amount of attention to methods and techniques; it would appear that a prior concern would be the determination of goals. Outcome studies have simply accepted and used any and all measures available, with little concern about their relevance to methods and techniques or to any desirable goals of the process. Mahrer's (1967) edited book, The Goals of Psychotherapy, revealed the almost endless number and variety of goals considered by the contributors. Parloff's (1967) contribution suggested a way of dealing with the problem. He proposed two levels of goals--mediating and ultimate. He notes that although there may be great differences in mediating goals, "differences in the stated ultimate goals will in all likelihood be small" (p. 9). Parloff's suggestion is the basis for the present discussion. Three, rather than two, levels of goals are considered, and the definitions of ultimate and mediating goals are different. The three levels are (1) the ultimate goal, (2) mediate or mediating goals, and (3) immediate goals. The last consists of the client's behavior in the process. THE ULTIMATE GOAL The ultimate goal in psychotherapy concerns the kind of person we want the client to become as a result of psychotherapy. It should be apparent that the kind of person we want the client to be is the kind of person we would like all persons to be. It relates to the question of what is the purpose of life, a question with which philosophers have been concerned since Aristotle. There have been many suggested goals. Jahoda (1958) proposed the concept of positive mental health, but it has been impossible to clearly define it. Concepts of adjustment raise the question of adjustment to what. White's (1959) concept of competence raises the question of competence for what. Psychological effectiveness involves the same problem. All require a higher level criterion. There are a number of terms or concepts that appear to transcend this question and to constitute an acceptable criterion. These include self-realization, self-enhancement, the fully-functioning person of Rogers, and self-actualization. This last term appears to be widely and commonly used, and is adopted here. The definition of the self-actualizing person derives form the work of Maslow (1956). He formulated a general definition of self-actualizing people as being characterized by the full use and exploitation of talents, capacities, potentialities, etc. Such people seem to be fulfilling themselves and to be doing the best that they are capable of doing. They are people who have developed or are developing the full stature of which they are capable (pp. 161-162). Selecting a group of people, living and dead, who seemed to represent self-actualizing people, Maslow attempted to find what these people had in common that differentiated them from ordinary people. Fourteen characteristics emerged: 1. More efficient perception of reality and more comfortable relations with it. 2. Acceptance of self, others, and nature. 3. Spontaneity; lack of rigid conformity. 4. Problem-centeredness: sense of duty, responsibility. 5. Detachment; need for privacy. 6. Autonomy, independence of culture and environment. 7. Continued freshness of appreciation. 8. Mystic experiences; oceanic feelings. 9. Gemeinshaftsgefühl; empathy, sympathy, compassion for all human beings. 10. Deep interpersonal relations with others. 11. Democratic character structure; respect for others. 12. Discernment of means and ends. 13. Philosophical, unhostile sense of humor. 14. Creativeness. (For more detail, see Maslow [1956] and Patterson [1985].) I pause to note some objections to the concept of self-actualization. These derive, in my opinion, from misconceptions or misunderstandings of the nature of self-actualization and of self-actualizing persons. One such objection is that self-actualization is inimical to individuality, since, it is claimed, self-actualization consists of a collection of traits that are the same for all persons, resulting in standard, identical behaviors. But what is actualized are varying individual potentials. As Maslow (1956, p. 192) notes, "selfactualization is actualization of a self, and no two selves are altogether alike." A second, and opposite, misconception is that a self-actualizing person is antisocial, or at least, asocial. Maddi (1973a, 1973b) has taken this position. Williamson (1950, 1958, 1963, 1965) also makes this criticism. And even Smith (1973) appears to see selfactualization as including undesirable, or antisocial behaviors, and thus unacceptable. And White (1973) appears to view self-actualization as selfish: "I ask readers," he wrote, "to observe carefully whether or not self-actualization, in its current use by psychological counselors and others, is being made to imply anything more than adolescent preoccupation with oneself and one's impulses" (White, 1973, p. 69). And Janet Spence, in her 1985 presidential address to the American Psychological Association (Spence, 1985) spoke as follows of the youth of the 60s and early 70s: Although some were led to careers that were expressions of idealism, others turned their backs on the work ethic or substituted as a goal for material success selfactualization and "doing your own thing". . . Although the pursuit of self-actualization was stimulated by rejection of materialistic goals, it represents another facet of unbridled materialism (pp. 1289-1290). These criticisms appear to confuse the concept of self-actualization with selfishness and self-centeredness, and identify it with the characteristics of the "me" generation of the 70s, the "culture of narcissism" (cf. Amitai Etzioni [1982], Christopher Lasch [1979] and Tom Wolfe [1976]). It is also perhaps influenced by the human potential movement, which no doubt, in many of its manifestations, promoted extreme individualism and selfcenteredness. Rogers answered these criticisms when he noted that individuals live in a society of others, and can become actualized only in interaction with others. They need others, and the affiliation, communication and positive regard of others (Rogers, 1959, 1961). Self-actualization as the goal of psychotherapy has some significant implications: 1. It constitutes a criterion in the sense that it is not vulnerable to the question: For what? Self-actualization avoids the problems of an adjustment model, which include in addition to the question adjustment to what, the questions of conformity and social control (Halleck, 1971). 2. Self-actualization as a goal avoids the problems of the medical model and its illness-health dilemma. The goal involves more than the elimination of pathology, and the achievement of some undefined (and undefinable) level of mental health or "normality." It is not a negative concept, such as the absence of disturbance, disorder, or "mental illness." It is a positive goal. 3. It eliminates the conflict or dichotomy between intrapersonal and interpersonal. It includes the whole person in a society of other persons. 4. The goal is a process, not a static condition to be achieved once and for all. It is the development of self-actualizing persons, a continuing process. An adequate goal for persons must be an ideal that is ever more closely approximated but never completely achieved. 5. Self-actualization as a goal is not limited to psychotherapy, or to the treatment of disturbed individuals. It is the goal of life, for all persons, all of whom are, to some degree, dissatisfied with themselves, unhappy, unfulfilled, and not fully utilizing their capabilities or potentials. Thus, self-actualization should be the goal of society and all of its institutions--education; marriage and the family; political, social and economic systems--all of which exist for the benefit of individuals. As a matter of fact, psychotherapy has come into existence as a way in which society provides special assistance to those whose progress toward self-actualization has been blocked, interrupted or impeded in some way, mainly by the lack of good human relationships. 6. There is another aspect of self-actualization that is particularly significant. Goals are related to--or are the adverse of--drives or motives. Thus when we talk about the goal of life, we become involved in purpose, needs, drives or motives, since goals are influenced by, indeed determined by, needs. Self-actualization is the basic motivation of all human beings, indeed of all living organisms. Goldstein (1939, p. 196), one of the earliest writers to adopt the term self-actualization, stated that "an organism is governed by a tendency to actualize, as much as possible, its nature in the world." The goal, then, is not an abstract, theoretical, philosophical, ethical or religious goal, but derives from the biological nature of the organism. 7. Since the drive toward self-actualization is biologically based, it is not time bound nor culture bound. It is thus a universal goal. And as a universal goal, not only for psychotherapy but for life, it provides a criterion for the evaluation of cultures. Maslow (1971, p. 213), influenced by the anthropologist Ruth Benedict, wrote: "I proceed on the assumption that the good society, and therefore the immediate goal of any society which is trying to improve itself, is the self-actualization of all individuals." (More extended discussion will be found in Patterson [1978, 1985].) 8. This formulation of the ultimate goal of psychotherapy resolves the problem of who selects the goal--the therapist or the client. Neither the therapist nor the client chooses this goal. It is a given; it is implicit in the nature of the individual as a living organism. It is the nature of the organism, a characteristic of Rogers's actualizing tendency, to grow, to develop, to strive to actualize its potentials, to become what it is capable of becoming-to be more self-actualizing. 9. Finally, the concept of self-actualization provides a solution to the problem of organizing needs in some hierarchy. All specific drives, including those in Maslow's (1970) hierarchy, are subservient to the drive toward self-actualization. All specific needs are organized and assume temporary priority in terms of their relevance to the basic drive toward self-actualization (Patterson, 1985). MEDIATE GOALS Mediate goals are the usual goals considered by counselors and psychotherapists. They include the specific and concrete goals of behavior therapists. Contributors to Mahrer's (1967) book focused upon this level of goals, such things as reduction of symptoms; reduction of anxiety, and of psychological pain and suffering, and of hostility; elimination of unadaptive habits, acquisition of adaptive habits. Other mediate goals include good marital and family relationships; vocational and career success and satisfaction; educational achievement, including study skills and good study habits; development of potentials in art, music, athletics, etc. The ultimate goal is a common goal, applicable to all individuals. Mediate goals provide for, or allow for, individual differences. People have differing, and multiple, potentials; they actualize themselves in differing ways. A number of implications of the separation of goals into ultimate and mediate become apparent: 1. While the ultimate goal is universal, applying across time and cultures, mediate goals vary with individuals, time and cultures. It is here that client choices and decisions operate. 2. Mediate goals may be considered as mediating goals, between the immediate goal and the ultimate goal. That is, they are steps toward the ultimate goal. In some instances they may overlap with aspects of the ultimate goal--the development of selfunderstanding, self-esteem, or self-acceptance, for example. 3. The ultimate goal provides a criterion for the acceptability of mediate goals, something that is lacking, or implicit, in behavior therapy. 4. While mediate goals may be considered as sub-goals, or steps toward the ultimate goal, they may also be seen as by-products of the ultimate goal. Self-actualizing persons normally and naturally seek to achieve the mediate goals on their own, or seek and obtain the necessary assistance, such as tutoring, instruction, information, education and training, or reeducation, to achieve them. As by-products, they are not necessarily goals to be directly achieved or specifically sought. Thus, in psychotherapy, mediate goals need not be determined or defined in advance, but are developed by the client during, or even following, the therapy process. It appears that it may be sufficient, in some cases, to provide the conditions leading to the development of self-actualizing persons; thus, as individuals become more self-actualizing, they develop, pursue and achieve their own more specific goals. 5. It is apparent that many of the mediate goals are the objectives of other helping processes, of education, reeducation and skill training. THE IMMEDIATE GOAL The mediating goals of Parloff (1967) are aspects of the psychotherapy process, the initiating and continuing of which is the immediate goal in the present model or system. The therapy process and its elements have been described in many ways, in the various theories of psychotherapy. Parloff (1967) included the following specific goals: making the unconscious conscious; recall of the repressed; deconditioning; counterconditioning; strengthening or weakening of the superego; development and analysis of the transference neurosis; promoting increased insight; increasing self-acceptance. There is little, if any, evidence that many of these goals lead to desirable therapy outcomes, particularly to increased self-actualization. An essential of the therapy process is client activity of some sort. Client activity involving self-exploration, or intrapersonal exploration, appears to be universally present in successful psychotherapy. It includes some of the mediating goals mentioned by Parloff, such as developing awareness of unconscious (or preconscious) material (selfawareness). The process of self-exploration is complex, involving several aspects or stages: 1. Self-disclosure. Before clients can explore themselves, they must disclose, or reveal, themselves, including their negative thoughts, feelings, problems, failures, inadequacies, etc. These are the reasons clients come for therapy, their "problems," and it is necessary to state the "problem" before it can be dealt with. Self-disclosure, or selfexposure, requires that clients be open and honest, or genuine. 2. Self-exploration. This consists of clients working with the disclosed material, exploring what and who they as persons really are. The self-exploration process may be slow, and not smooth or continuous. There is resistance to looking at and facing up to one's undesirable aspects. 3. Self-exploration leads to client self-discovery, an awareness of what one is really like. 4. With self-discovery comes self-understanding. Clients become aware of failures to actualize themselves and their potentials. They see the discrepancies between their actual selves and their ideal selves. They begin to reduce the discrepancies, modifying their actual or ideal selves, or both. A realistic self-concept is developed, a self-concept more congruent with experience. Clients are able to accept themselves as they are, and to commit themselves to becoming more like they want to be (see Patterson [1985] and Rogers [1961], especially, for fuller discussions of the therapy process in the client). Questions have been raised about self-disclosure and self-exploration by writers about cross-cultural counseling. Persons in other cultures (as well as the poor in our own culture [Goldstein, 1973]), it is said, cannot, or do not, engage in self-disclosure or selfexploration (or "introspection"). Pedersen, for example, referring to American Indian clients, writes: "A counselor who expects clients to verbalize their feelings is not likely to have much success with Native American clients" (Pedersen, 1976, p. 26). Sue (1981, p. 48) refers to "certain groups" (Asian Americans, Native Americans, etc.) that dictate against self-disclosure to strangers. He refers (p. 38) to "the belief in the desirability of self-disclosure by many mental health practitioners." Yet, paradoxically, he also refers to self-disclosure as an "essential" condition that is "particularly crucial to the process and goals of counseling ...." (Sue, 1981, p. 48). That is the problem. If self-exploration is essential for progress in psychotherapy (and this is supported by the research), then it cannot be abandoned, as some suggest, with the therapist taking an active, directing, leading or structured approach. But client reluctance to self-disclose or difficulty in self-disclosing is a social, not a purely cultural characteristic. People (in general, not only Asians) do not disclose to strangers, social superiors, experts, including professionals. Yet, paradoxically, people sometimes tell things to strangers (as well as to therapists) that they wouldn't tell to families or friends. Chinese with whom I have talked assure me that they self-disclose among their families and friends. The reluctance to self-disclose or difficulty in selfdisclosing among certain clients is not a reason for abandoning psychotherapy (for which it is a necessary condition), but for providing the conditions which make client selfdisclosure possible. THE CONDITIONS How does the therapist make it possible for the client to engage in those activities necessary for therapeutic progress? He or she does so by providing certain conditions. Three major conditions have been identified and defined (Rogers, 1957) and are now supported by considerable research (Patterson, 1984, 1985). The nature of these conditions is now well known, and they are simply enumerated here. 1. Empathic understanding, an understanding of the client from his or her frame of reference, and the communicating of this understanding. 2. Respect, unconditional positive regard, the manifestation of a deep interest, caring, concern, even compassion for the client. 3. Therapeutic genuineness, congruence in the therapist, an authenticity, transparency, honesty. It is necessary that the adjective therapeutic be used, since the term genuineness alone has led to therapists manifesting behaviors, under its guise, that are harmful to clients. There is another condition, that may be more a technique than a condition, that I believe has the status of a necessary element in the therapist's behavior: 4. Concreteness or specificity in responding to client productions. This is the opposite of abstractions, labels, generalizations or interpretations, all of which, rather than encouraging client self-exploration, stifle or extinguish it. These four conditions may be summed up, I think, in the concept of love, in the sense of agape. They are part of all the great world religions and philosophies. In 1986, Dr. Louis Thayer interviewed Carl Rogers. At one point in the interview, when Rogers commented on the presence of too much intervention, by parents, governments and policy makers (as well as by therapists), he stopped to take from his wallet a verse he carried with him, "a little quotation I treasure," he said. It is this poem by Lao Tzu, a Chinese philosopher of the 5th Century B.C. that I have been using this in my teaching for several years, substituting therapist for leader: A Leader (Therapist) A leader (therapist) is best when people [clients] hardly know he exists; Not so good when people [clients] obey and acclaim him; Worst when they despise him. But of a good leader [therapist] who talks little, When his work is done, his aim fulfilled, They will say, "We did it ourselves." The less a leader [therapist] does and says, The happier his people [clients]; The more he struts and brags, The sorrier his people [clients]. [Therefore] a sensible man says: If I keep from meddling with people [clients], they take care of themselves. If I keep from commanding people [clients], they behave themselves. If I keep from preaching at people [clients], they improve themselves. If I keep from imposing on people [clients], they become themselves. CLIENT CONDITIONS Psychotherapy is of course a two way process, a relationship, and it takes two to form a relationship. There are two conditions that must be present in the client before the process of therapy can begin. 1. Therapy cannot be imposed on a passive, so-called involuntary client. The client must be "motivated." Rogers (1957, p. 96) states as one of the conditions of therapeutic personality change that the client "is in a state of incongruence, being vulnerable or anxious." That is, he or she "must be someone who is feeling some concerns . . . some degree of conflict, some degree of inner difference, some expression of concern." (Rogers, 1987, pp. 39, 40). 2. The client must perceive the conditions offered by the therapist. "The communication" to the client of "the therapist's empathic understanding and unconditional positive regard is to a minimal degree achieved" (Rogers, 1957, p. 96). CHARACTERISTICS OF THE SYSTEM There are some characteristics of this system of psychotherapy that are worth noting: 1. Note the similarities in the Goals, the Process, and Conditions. All include empathy, respect, and genuineness or honesty. The conditions are also the goal. 2. The client, in becoming more self-actualizing becomes a therapeutic influence on others, contributing to their self-actualizing progress. 3. The conditions operate in a number of ways, consistent with our understanding of the learning or change process. a. The conditions create a nonthreatening environment, in which the client can feel safe in self-disclosing and self-exploring. A high level of threat, as is well known, is inimical to learning. The warm, accepting atmosphere provided by the therapist contributes to desensitizing the client's anxieties and fears in human relating, and inhibitions about self-disclosure. b. The psychotherapeutic process is not a straight-line progression, but is like the typical learning process, with plateaus or even regressions. The client evidences the approach-avoidance conflict, progressing up to the point when internal threat or anxiety becomes too great, then retreating or "resting" until the anxiety is reduced. Nor is the process one in which separate problems are worked on until each is resolved. All problems interrelate, and the client grapples with one for a while, then may move on to another, and another, then returning to each in an alternating or spiraling process. c. The conditions provide an environment for self-discovery learning. While discovery learning is not always possible or desirable in other areas, it is the most relevant and most effective method for learning about oneself. d. The conditions are the most effective reinforcers of the desired client behavior of self-exploration. More broadly, love is the most potent reinforcer of desirable human behavior. e. The conditions also operate through modeling. The client becomes more like the therapist in the therapy process. It follows that the therapist, to be a model, must be at a higher level of the conditions, and of the self-actualizing process, than the client. f. The conditions, when offered at a high level by the therapist, include the expectation by the therapist of change in the client. Expectations have a powerful effect on the behavior of others. g. The therapist conditions free the actualizing tendency in the client, so that he or she can become a more self-actualizing person. 4. The conditions are the specific treatment for the lack or inadequacy of the conditions in the past and/or present life of the client. This lack is the source of most functional emotional disturbances, and of failures in the self-actualizing of human beings. 5. The conditions constitute, or include, the major basic, general, enduring and universal values of life. They are necessary for the survival of a society or culture. Society could not exist if these conditions were not present in its members at a minimal level. They are the conditions necessary for human beings to live together and to survive as a society. Skinner (1953, p. 445) wrote: "If a science of behavior can discover those conditions of life which make for the ultimate strength of men, it may provide a set of 'moral values' which, because they are independent of the history and culture of any one group, may be generally accepted." We have those values (Patterson, 1966). 6. 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