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Professional Counseling and Dr. Glasser: A Relationship Based on Reality and Choice
Mark Pope
The Family Journal 2004; 12; 345
DOI: 10.1177/1066480704268422
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THE FAMILY
10.1177/1066480704268422
Pope
/ PROFESSIONAL
JOURNAL:
COUNSELING
COUNSELING
AND
AND
GLASSER
THERAPY FOR COUPLES ANDAMILIES
F
/ October 2004
Professional Counseling and Dr. Glasser:
A Relationship Based on Reality and Choice
Mark Pope
University of MissouriSt. Louis
FOUNDATIONS OF PROFESSIONAL COUNSELING
This article looks at the historic foundations of professional counseling and then summarizes William Glassers most recent ideas as presented in this issue of The Family Journal. Although psychiatry,
psychology, and social work have embraced the medical and mental
illness models, professional counseling continues to have a strong
focus on health, wellness, growth, development, and prevention.
Professional counselors know that Glasser is correct when he asserts that mental health (as opposed to illness) is most important.
Keywords:
mental health; counseling; medical model; metaanalysis; common factors
irst, let me say how much I respect the work of William
Glasser. He has been and continues to be one of the foremost theoreticians in the field of professional counseling. His
work is reality based, pithy, and thoughtful. He is masterful in
getting his work out into the world, into the hands of professional counselors and others who would use his theory to
guide their work.
Glasser (2004 [this issue]) has provided here what he
called a new vision for counseling. His new vision for counseling builds forcefully on the historic identity of professional
counseling, and he has called on us to look at his choice theory as the method to achieve our mutual goals in society. It is
important to note that both Glasser and I use the terms counseling and psychotherapy interchangeably, as any historical
differentiation is no longer valid.
In this article, I look at the historic foundations of professional counseling and then summarize Glassers most recent
ideas as presented in this issue of The Family Journal. This is
followed by an analysis of the extant outcome research in
mental health to see if there is any evidence that any specific
theory or technique is better than another specific theory or
technique. Such evidence would be compelling in accepting
Glassers proposal for our profession.
Authors Note: Correspondence concerning this article should be
directed to: Mark Pope, Ed.D., Associate Professor, Division of
Counseling & Family Therapy, University of MissouriSt. Louis,
8001 Natural Bridge Road, St. Louis, Missouri 63121-4499; E-mail:
pope@umsl.edu.
The American Counseling Association was born in 1952
from the need of diverse counseling and guidance professionals for a larger voice in the world. There were four founding
independent professional associations: National Vocational
Guidance Association (now the National Career Development Association, an organization of career counselors and
other career development professionals), National Association of Guidance and Counselor Trainers (now the Association for Counselor Education and Supervision), the Student
Personnel Association for Teacher Education (now the Counseling Association for Humanistic Education and Development), and the American College Personnel Association.
They were soon joined by the American School Counselor
Association to form the nucleus of a new professionprofessional counseling. What bound these groups together was
their common belief that all human beings are constantly
striving toward mental health and wellness (Aubrey, 1977;
Brewer, 1942; Coy, Sheeley, & Engels, 2003; Herr, 1974;
McDaniels, 1964; Newcombe, 1993; Norris, 1954; Pope,
2000; Salomone, 1988; Savickas, 1993; Sprinthall, 1977;
Whiteley, 1984).
The roots of professional counseling are in a variety of
other professions and include the social work profession,
applied psychology, assessment, humanism/progressivism,
multiculturalism, medicine, and the schools. But professional
counseling has grown and developed during the past 100
years, and we are now so much more than just our initial parts.
Traditional social work focuses on case management
not counseling. Those in the mental health specialization of
social work are trained in the clinical aspects, but almost 90%
of the other social workers are policy-and-case-management
focused and their respective internships, although thorough,
are not counseling focused.
Our psychological ancestors have taken a more medical
focus in their work. Even the counseling psychologists have
abandoned the schools (not all) and a more traditional developmental and preventive focus (Pope, 2004). Some still mouth
the words of primary prevention, but it is sometimes hard to tell
a clinical from a counseling psychologist these days.
THE FAMILY JOURNAL: COUNSELING AND THERAPY FOR COUPLES AND FAMILIES, Vol. 12 No. 4, October 2004 345-349
DOI: 10.1177/1066480704268422
2004 Sage Publications
345
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346 THE FAMILY JOURNAL: COUNSELING AND THERAPY FOR COUPLES AND FAMILIES / October 2004
MENTAL HEALTH OR MENTAL ILLNESS
In November 2003, I represented the American Counseling Association at the Jimmy and Rosalyn Carter Centers
annual Mental Health Symposium in Atlanta, Georgia, where
all of the mental health organizations in the United States
gathered to discuss the implementation of the report of President Bushs New Freedom Commission on Mental Health. A
similar commission was initiated 25 years ago by President
Jimmy Carter, and its report led to the demise of residential
treatment of the mentally ill and to the rise of the community
mental health movement.
I have not been around a lot of psychiatrists recently (I had
enough of them in my early career in psychiatric hospitals and
drug abuse treatment) . . . until this meeting. First, you should
know that I do not tolerate arrogance easily. I had forgotten
how wonderful psychotropic medications are and how everything can be fixed by such pills. Not. I had forgotten how
much verbal and behavioral therapies are valued by this
group. Not. And I had forgotten how much psychiatrists are
valued by the other medical specialties, such as surgery and
oncology. Double not. Remember that even psychiatry is
looked down on (by the hard science medical faction) as a
soft or fuzzy part of medicine. Remember also that medical schools have a strongly hierarchical and patriarchal structure, and that psychiatrists are trained in medical schools.
(You knew that, just wanted to remind you.)
It was quite entertaining and eye opening. I realized (once
again) why I strongly identify as a professional counselor. I
am pretty sure that everyone who is a professional counselor
should have this experience at least once in their lifetime, as it
made me appreciate what we bring to the whole mental health
equation in the world, why we are unique, and our reason for
existence.
We are the developmentalists who focus on the life transitions of people. While many of our mental health colleagues
are focusing on illness, we are focusing on health, wellness,
growth, development, and prevention. Insurance companies
do not much like such language, as they are focused on making a profit for their shareholders and feel that prevention
costs money up front that affects this years annual report.
This shortsighted belief is what drives mental illness models and traditional Western symptomatic medicine approaches.
It keeps us all trapped.
Fortunately, much of what was presented at the Carter
Center Mental Health Symposium was focused on what our
profession knows and does everyday. Here are some of those
new-to-them truths uncovered by researchers and presented
to the very astute and attentive audience at this national
symposium:
1. The big three in mental health recovery are prevention, early
diagnosis, and treatment.
2. Suicide is the leading cause of violent deaths in the world
(suicide 49%, homicide 32%, war 19%).
3. Of those with diagnosable mental disorders, only half get
some treatment.
4. The most serious of the mental disorders begin in childhood
and adolescence. Note that 15 years old is the age of onset of
50% of those who are diagnosed with anxiety disorders. This
is a worldwide statistic.
5. Poverty has a strong relationship with mental illness.
6. Collaborative care models (integrated care where we all
work together) have been shown to dramatically improve the
treatment of mental health disorders (but this is always the
first model to not be implementedusually for cost reasons,
not for efficacy, obviously).
7. We cannot reach children and adolescents through mental
health clinics and hospitals. The primary gathering place for
children and adolescents is the schools (followed closely by
shopping mallssmile).
8. Even if there are genes for depression or chemicals to relieve
symptoms, those who have them will still need psychosocial
supportive therapies to survive the experience and relearn
developmentally appropriate healthy behaviors so that they
can achieve recovery and true mental health.
This statement was made on various occasions: Mental
health is more than the lack of mental illness. Even if you
identify a pathogen (genetic, hormonal, chemical imbalance)
and you eliminate/correct it, what is left? Such simple elimination does not assure full recovery, as there will generally
remain behavioral/developmental deficits. You must
acknowledge the developmental anomalies that persist, that
the learned compensatory behavior does not just simply correct itself. Sometimes, yes, with time and a healthy environment, but rarely. The old behaviors learned to cope with the
pathogen will not just evaporate; nature abhors a vacuum.
Alleviation of symptoms and elimination of the pathogen is
the foundation on which health is built, but it is not sufficient
in and of itself to assure a true mental health.
The Commission on Mental Health had some recommendations that I think most of us will applaud vigorously. Here
are a few:
Abandon the language of stigma, and embrace a recovery and
resilience paradigm.
Normalize mental health treatment.
Individualize mental health treatment.
Inform other mental health professions about what each
does and then integrate service delivery as well as professional literatures.
Teach young people about differences.
Use strength-based language rather than deficit based.
Use the school-based mental heath practitioners (school
counselors, school social workers, school psychologists) to
provide screening, assessment, treatment, and referral.
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Pope / PROFESSIONAL COUNSELING AND GLASSER 347
Integrate the delivery of mental health services throughout
the various institutions of the community.
We cannot afford to have mental health left to the mental
illness people, as Glasser continues to remind us.
A SUMMARY OF GLASSERS PROPOSAL
FOR PROFESSIONAL COUNSELING
Let me summarize Glassers (2004) proposal that he succinctly presented in his article:
1. Professional counselors counsel and teach clients to improve
their own mental health to the point that they will no longer
need counseling.
2. More people are currently diagnosed as mentally ill than at
any time in psychiatric history and are then being treated
with some form of psychotropic medication (brain drugs).
3. Surgical lobotomies were performed in the United States
from 1940 to 1970, but now, through the use of psychotropic
medication, we see essentially chemical lobotomies being
performed daily.
4. Unhappiness is the underlying problem for everyone.
5. External control psychology is what is currently used by
most people to guide how they deal with the people they cannot seem to get along with in their life, especially in couple
relationships. I can make other people do what I want if I
apply enough coercion.
6. Replacing external control behaviors with choice theory
behaviors is the essence of effective counseling.
7. All living creatures are genetically driven to behave by basic
needs. The basic needs of all mammals who nurse are survival, love and belonging, freedom, and fun. In addition,
humans are driven by power.
8. The only chance for mental health and happiness is to learn to
replace external control with choice theory, and this is the
core of teaching and achieving mental health through
counseling.
9. The Diagnostic and Statistical Manual of Mental Disorders
(4th ed.) (American Psychiatric Association, 1994) is the
big red book of unhappiness.
10. There are real brain diseases caused by brain pathology (e.g.,
Parkinsons and epilepsy), but they fulfill specific neurological criteria that can be demonstrated by specific medical tests
such as a CAT scan or magnetic resonance imaging (MRI).
11. Mental disorders that are diagnosed and described in DSMIV cannot satisfy these physiological criteria. They are diagnosed through common sense (that was formed under external control psychology) not by physiological science.
12. The logic goes like this: If there is no pathology, there is no
brain disease; if there is no brain disease, there is no medical
reason to use psychotropic medication.
13. Psychotropic medication may seem to help or alleviate
some psychological symptoms, but there is no evidence that
any such drug has ever cured such symptoms. The action is
either placebo or sedation that makes the patient easier to
manage.
14. One side effect of such medication can be a pleasurable
amphetamine-like lift that can be addictive.
15. There are two kinds of pleasure: pleasure derived from
human relationships and pleasure derived without people,
such as addictions (drugs, gambling, etc.).
16. To succeed, the counselor must develop the skill to form a
good relationship with all people that he or she counsels.
17. The answer is mental health through choice theory.
18. Professional counseling should adopt the theme Effective
mental health without drugs.
INTEGRATING CHOICE THEORY
WITH PROFESSIONAL COUNSELING?
In Glassers (2004) article, he presented a succinct and
compelling argument for why professional counselors should
ally themselves with his choice theory. That article does not,
however, provide an in-depth analysis of the data on which
his theory is based. Such data are thoroughly and convincingly presented in his most recent book (Glasser, 2003). We
are expectedas intelligent consumers of the literature of our
professionto refer to that book for more of those data. Glassers summation of that research is useful, but let me present
some of the most current data from our field that are important to understanding and appreciating a couple of his major
points.
In the mental health professions, we have begun to look at
outcomes much more. One specific method is now being used
to analyze the plethora of data currently available from the
past 40 years. That method is the meta-analysis. The metaanalysis is a procedure that analyzes the findings of all of the
accumulated research that has been collected on a particular
subject to look for overall trends supported by those data.
This is particularly useful when you have studies that appear
to be contradictory, as this type of analysis can tease out the
relative truths where available (Wampold, 2001; Wampold
et al., 1997).
The data are clear that there are four factors that contribute
to successful outcomes in counseling: client factors, relationship factors, placebo/expectancy factors, and model/technique
factors. Each contributes differently as outlined below (Nathan
& Gorman, 2002; Norcross, 2002; Rosenzweig, 1936; Wampold, 2001).
The client actually provides the most important contribution to a successful outcome. Such factors as persistence,
optimism, openness, faith, or supportive role models are all
part of a clients makeup when they present for counseling.
The other piece of this puzzle is serendipitous events such as a
new job or a crisis successfully negotiated. This accounts for
40% of any behavioral changes.
The next most important factor in a successful therapeutic
outcome is the clients perception of the counselor/client relationship. The clients favorable ratings of that relationship are
the best predictors of such successmore predictive than the
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348 THE FAMILY JOURNAL: COUNSELING AND THERAPY FOR COUPLES AND FAMILIES / October 2004
diagnosis, the counselor, the intervention method, or anything. This accounts for 30% of the changes.
The third most important factor is a placebo or expectancy
factor that derives from the clients knowledge of being
helped, the instilling of hope, and the credibility of the counselors rationale and techniques. This accounts for 15% of the
changes.
The fourth and final factor is the actual technique or theory
that a counselor employs in the sessions. Not one specific
technique or theory has demonstrated superiority over any
other in comprehensive meta-analytic analyses. This
accounts for the final 15% of the changes.
As can be seen from such data, the actual technique or a
specific theory accounts for some but very little of the
changes that are seen in counseling. And although such findings work against recommending one particular therapeutic
model over another, Glasser (2003) has also told us that it is
the relationship first.
THE MEDICAL MODEL VERSUS THE
CONTEXTUAL/RELATIONSHIP MODEL
Glassers (2003) recent work is not just an indictment of
the brain drugs. It is also an indictment of the medical model
of mental illness where diagnosis plus treatment equals cure
and more often than not, the treatment includes some type of
psychotropic medication. Wampold (2001) conducted a comparative meta-analysis of two models of counseling: the medical model and a contextual/relationship model based on individual and relationship factors. In his analyses, he reviewed
the literature related to the absolute efficacy of psychotherapy, relative efficacy of various treatments, specificity of
ingredients contained in established therapies, effects due to
common factors such as the working alliance, adherence and
allegiance to the therapeutic protocol, and effects that are produced by different therapists. Wampold found that the evidence convincingly corroborated the contextual model and
disconfirmed the prevailing medical model.
CONCLUSIONS
Glassers (2004) article has at least two purposes: first, to
detail his vision of what professional counseling ought to be
and ought to be doing and second, to persuade us that his theory is the vehicle for activating such a vision. And I agree with
his assumptions, values, and beliefs, I just do not think that
professional counseling should put all of our eggs in one nest,
even when that nest is a very good one.
What we know from all of the accumulated research during the past 100 years is that professional counseling works,
but that not one theory has proven itself to be better than
another (yet). In fact, we have considerable evidence that
makes it clear that the similarities rather than the differences
between models account for most of the change that clients
experience across therapies (Duncan & Sparks, 2000, p. 60).
What is most important for professional counselors is that
we have a theory we follow that provides a structure for our
work, that we know how to build and maintain a relationship
with our clients, and that we do it.
It is important for professional counselors to know that the
assumptions and values of Glassers (2003, 2004) work do
come straight out of the historical foundations of professional
counseling. Professional counselors know that Glasser is correct when he asserts that mental health is most important. We
have been living this through our work since before the
founding of our profession and especially before the newest
fad, positive psychology, caught the interest of psychologists. Our colleagues in counseling psychology and vocational psychology have known this but have been unable to
get a hold of their profession (psychology) and turn it away
from the medical and mental illness model about which
Glasser has forcefully and consistently written.
Although I would not choose Glassers choice theory for
all of professional counseling, I would not choose any theoretical model for our entire profession. I would, however, recommend that we listen closely to Dr. Glasser, for it is but an
anomaly that he is trained as a psychiatrist, for he is a kindred
spirit to professional counselors. He is a believable and potent
speaker for our shared cause that includes effective mental
health without drugs.
REFERENCES
American Psychiatric Association. (1994). Diagnostic and statistical manual
of mental disorders (4th ed.). Washington, DC: Author.
Aubrey, R. F. (1977). Historical development of guidance and counseling and
implications for the future. Personnel and Guidance Journal, 55, 288295.
Brewer, J. M. (1942). History of vocational guidance. New York: Harper &
Brothers.
Coy, D. R., Sheeley, V. L., & Engels, D. W. (2003). American Counseling
Association: A 50 year history 1952-2002. Alexandria, VA: American
Counseling Association.
Duncan, B., & Sparks, J. (2000). Heroic clients, heroic agencies: Partners for
change. Ft. Lauderdale, FL: Nova Southeastern University.
Glasser, W. (2003). Warning! Psychiatry can be hazardous to your mental
health. New York: HarperCollins.
Glasser, W. (2004). A new vision for counseling. The Family Journal, 12(4),
339-341.
Herr, E. L. (1974). Manpower policies, vocational guidance and career development. In E. L. Herr (Ed.), Vocational guidance and human development
(pp. 32-62). Washington, DC: Houghton Mifflin.
McDaniels, C. O. (1964). The history and development of the American Personnel and Guidance Association 1952-1963. Unpublished doctoral dissertation, University of Virginia, Richmond.
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Pope / PROFESSIONAL COUNSELING AND GLASSER 349
Nathan, P. E., & Gorman, J. M. (Eds.). (2002). A guide to treatments that work
(2nd ed.). New York: Oxford University Press.
Wampold, B. E. (2001). The great psychotherapy debate: Models, methods,
and findings. Mahwah, NJ: Lawrence Erlbaum.
Newcombe, B. H. (1993). The historical descriptive study of the American
Personnel and Guidance Association from April 1963 through July 1983.
Unpublished doctoral dissertation, Virginia Polytechnic Institute and
Wampold, B. E., Mondin, G. W., Moody, M., Stich, F., Benson, K., & Ahn,
H.-N. (1997). A meta-analysis of outcome studies comparing bona fide
psychotherapies: Empirically, all must have prizes. Psychological Bul-
State University, Blacksburg.
Norcross, J. C. (Ed.). (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patient needs. New York:
letin, 122, 203-215.
Whiteley, J. (1984). Counseling psychology: A historical perspective.
Schenectady, NY: Character Research.
Oxford University Press.
Norris, W. (1954). Highlights in the history of the National Vocational Guidance Association. Personnel and Guidance Journal, 33, 205-208.
Pope, M. (2000). A brief history of career counseling in the USA. Career
Development Quarterly, 48, 194-211.
Pope, M. (2004). Counseling psychology and professional school counseling: Barriers to a true collaboration. The Counseling Psychologist, 32,
253-262.
Rosenzweig, S. (1936). Some implicit common factors in diverse methods of
psychotherapy. American Journal of Orthopsychiatry, 6, 412-415.
Salomone, P. R. (1988). Career counseling: Steps and stages beyond Parsons.
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Savickas, M. L. (1993). Career counseling in the postmodern era. Journal of
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Sprinthall, N. A. (1977). Psychology and teacher education: New directions
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Mark Pope is an associate professor in the Division of Counseling &
Family Therapy at the University of MissouriSt. Louis. His work is
published as books and book chapters, as conference presentations,
and in such journals as Journal of Counseling and Development,
The Counseling Psychologist, Career Development Quarterly, Journal of Vocational Behavior, The Family Journal, and Journal of
Multicultural Counseling and Development. He has served as president of the American Counseling Association, the National Career
Development Association, and the Association for Gay, Lesbian,
and Bisexual Issues in Counseling. He is a fellow of the National
Career Development Association, Society of Counseling Psychology, and American Psychological Association. He has written on the
history of and public policy issues in counseling; psychological testing; violence inn the schools; the career development of ethnic,
racial, and sexual minorities; teaching career counseling; and international issues in counseling. He was most recently named as the
incoming editor of Career Development Quarterly.
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