A solution-focused approach to rational-emotive behavior therapy: toward a theoretical integration
A theoretical integration of rational emotive behavior therapy (REBT) and solution-focused therapy is described. It is suggested that the integrative conceptualization underscores these models’ complementary aspects by addressing the limitations of each and enhancing their respective strengths. The clinical theory and process of the integrative model is explicated along with a case example. Directions for future theory building, research, and practice are considered.
In the last quarter century, there has been an increasing literature regarding the merits and limitations of integrating diverse therapy models. It has been suggested that the movement toward integration is reflective of a trend that recognizes the restraints of adhering to a single-based clinical theory and the benefits of rapprochement, dialogue, and convergence between schools (Norcross & Goldfried, 1992; Safran & Messer, 1997). Proponents of the integrative movement recognize that no single model is adequate to account for all clients and problems. For example, Liddle (1982) has suggested that “the tendency toward integrationism seems related⋖to our frustration with the limits of any one approach or perspective” (p. 247). As a result, numerous integrative models have been set forth in which disparate theories are combined in a multitude of ways.
The literature on integration has become proliferating, complex, and at times, confusing. A consensus has been reached among some theorists, however, with regard to the meanings of some of the prevailing terms used to describe integrative models. For example, many writers have agreed that theoretical integration refers to combining two or more distinct theories and thereby producing a new, superordinate clinical framework (e.g., Norcross, 1990; Safran & Messer, 1997). Various theoretical integrations have been proposed. In this article, we present an integration of Ellis’s (1996, 1999, 2001) rational emotive behavior therapy (REBT) and the solution-focused therapy model developed by de Shazer (1985, 1988, 1991) and de Shazer et al. (1986). This model describes and explains some of our most recent work with clients.
In REBT, clinical problems are conceptualized as largely the result of irrational beliefs, which consist of demands that humans escalate from their healthy preferences (Ellis, 1996). The primary goal in REBT is to help clients replace irrational beliefs with rational beliefs through various cognitive, emotive, and behavioral techniques. In contrast, solution-focused therapy conceptualizes problems in terms of the clients’ talk or “languaging” about problems and the necessary existence (either actual or potential) of exceptions (i.e., times when the problem is not happening); in other words, problem/exception (de Shazer, 1991; de Shazer et al., 1986). Solution-focused therapy tends to emphasize clients’ existing strengths, rather than their deficits, and often focuses on minimalist goals. REBT, on the other hand, places more emphasis on deficits (i.e., irrational beliefs) and seeks a large scope of change by helping clients adopt a rational philosophy of life. Despite these differences, leading proponents of REBT and solution-focused therapy have suggested that there is significant overlap between these models and, moreover, at times their presumed differences might be indiscernible (e.g., Ellis, 1996; Molnar & de Shazer, 1987).
Petzold (1981) has proposed an integration of the clinical approaches of REBT’s Albert Ellis and Milton H. Erickson (1980), a theorist who has significantly influenced the development of solution-focused therapy. Our review of the literature, however, indicates that there is a paucity of writing on the topic of integrating REBT and solution-focused therapy. In this article, the position is taken that there is a bonus to be attained by systematically integrating the clinical theories of REBT and solution-focused therapy. In particular, it is suggested that an integrative conceptualization underscores these models’ complementary aspects; that is, the integration compensates for their respective weaknesses and enhances the strengths of each individual model. The result is a new clinical approach that is more comprehensive than either of the singular models. The organization of this article is as follows. First, the clinical theories of REBT and solution-focused therapy are described. Next, the integrative clinical theory is set forth. The clinical process of the integrative model is then explicated along with a case example. Finally, directions for future theory building, research, and practice are considered.
Rational Emotive Behavior Therapy
Ellis (1988) has suggested that “you can figure out by sheer logic that if you were only⋖to stay with your desires and preferences, and if you were never⋖to stray into unrealistic demands that your desires have to be fulfilled, you could very rarely disturb⋖yourself about anything” (p. 21). From this thought flows REBT’s most fundamental principle, namely, that emotional and behavioral disturbance is largely caused by demandingness (Ellis, 1962, 1988, 1996, 2001). REBT’s theory describes the processes whereby humans create irrational (i.e., self-defeating) philosophies and then indoctrinate themselves with these ideas. In addition, REBT contends that humans are taught irrational philosophies and frequently internalize these ideas through persistent self-indoctrinations. According to REBT, humans make themselves disturbed by thenceforth bringing irrational philosophies to situations in their lives.
REBT theory is specified further by way of its distinction between rational beliefs and irrational beliefs. According to REBT, rational beliefs are evaluative cognitions that are nonabsolute and take the form of preferences, desires, and wishes (Ellis, 1962, 1996; Ellis & Dryden, 1990). Ellis and Dryden (1990) have suggested that rational beliefs are relative and do not interfere with the attainment of basic goals. Irrational beliefs, on the other hand, tend to be absolute, dogmatic, and demanding and take the form of musts, shoulds, and oughts (Ellis, 1962, 1996). When humans hold irrational beliefs about negative events in their lives, these generally correspond to self-defeating (also referred to as inappropriate) emotions and behaviors (e.g., depression, anxiety, addiction) that usually block one from working toward their goals (Ellis, 1996). Rational beliefs about negative events tend to result in self-helping (also referred to as appropriate) emotions and behaviors (e.g., sadness, concern, annoyance) that aids one in working toward their goals (Ellis, 1996).
REBT’s ABC theory explains quite simply the processes whereby humans become emotionally and behaviorally disturbed (Ellis, 1962, 1988, 1996). A stands for Activating events. B stands for Beliefs. C stands for emotional and behavioral Consequences. REBT holds that Activating events (A) do not directly cause emotional and behavioral Consequences (C). Instead, it is one’s Beliefs (B) about Activating events (A) that contribute most to emotional and behavioral Consequences (C). REBT’s ABC theory posits that appropriate emotional and behavioral Consequences (C) are largely caused by rational Beliefs (B) about Activating events (A). Conversely, inappropriate emotional and behavioral Consequences (C) are mainly caused by irrational Beliefs (B) about Activating events (A). REBT’s main clinical goal is to help individuals dispute irrational beliefs and, in turn, eradicate emotional and behavioral problems so that they can work toward their goals in an effective and efficient manner (Ellis, 1996). The course of REBT includes introducing to clients the principles of REBT, and helping them use various cognitive, emotive, and behavioral techniques aimed at disputing irrational beliefs and modifying dysfunctional feelings and behaviors. The disputation method, REBT’s principal technique, has been defined as “any process where a client’s irrational beliefs and cognitive distortions are challenged and restructured” (Ellis, Sichel, Yeager, DiMattia, & DiGiuseppe, 1989, p. 34). REBT also employs a variety of behavioral and emotive technique aimed at helping clients change their self-defeating thoughts, feelings, and behaviors.
(a) “I must achieve outstandingly well in one or more important respects or I am an inadequate person!” (b) “Other people must treat me fairly and well or they are bad people!” (c) “Conditions must be favorable or else my life is rotten and I can’t stand it!” (p. 155)
In solution-focused therapy, the notion of problem has within it the seeds of solution insofar as there are always exceptions (de Shazer, 1982, 1985, 1988, 1991; de Shazer et al., 1986; O’Hanlon & Weiner-Davis, 1989). Hence, a clinical problem is conceptualized as problem/exception. The change process results from identifying and amplifying exceptions. Clinicians use interventive questions to help clients identify exceptions; for example, “When has there been a time when you have coped better with this problem?” Exceptions may be amplified by encouraging clients to do more of the behaviors that have led them to solve the problem in the past, to observe times when they are dealing better with the problem, or to ascribe meaning to exceptions. The criterion for problem resolution in solution-focused therapy is that the presenting problem is sufficiently improved or sufficient progress has made been made in the direction of the goal.
times when the⋖problem does not happen even though the client has reason to expect it to happen, and, of course, the space between problem and non-problem or the areas of life in which the problem/non-problem is not an issue and is not of concern to the client. (p. 83)
The process of solution-focused therapy usually involves five stages: (1) constructing a problem and goal, (2) identifying and amplifying exceptions, (3) interventions or tasks designed to identify and amplify exceptions, (4) evaluating the effectiveness of interventions, and (5) re-evaluating the problem and goal. In solution-focused therapy, the client and therapist collaborate to define a problem and goal. The problem definition is then subsumed by the problem/exception conceptualization. For example, if a client were to define the problem as frequent arguing with their spouse, the problem would be conceptualized as arguing with my spouse/not arguing with my spouse. In many cases, problem resolution is attributed to the client’s own view that he or she is no longer experiencing the problem. This might be related to an increase in exceptions or an increase in the client’s awareness of exceptions. In each case, however, change is facilitated by the client’s ascribing significant meaning to the exceptions. As de Shazer (1991) has suggested, “for the client, the problem is seen as primary (and the exceptions, if seen at all, are seen as secondary), while for therapists the exceptions are seen as primary; the interventions are meant to help clients make a similar inversion, which will lead to the development of a solution” (p. 58).
Integrative Clinical Theory
It follows that disturbance is to be understood in terms of the coexistence of rational beliefs and irrational beliefs. The change process entails helping the client replace irrational beliefs with rational beliefs by identifying and amplifying rational exceptions: instances when, in the context of clinical disturbances, the client retains their preference (rational belief), yet does not escalate that desire into a demand (irrational belief). We recognize that there are also always general exceptions to clinical problems; that is, any instance when the client has experienced some improvement in their self-defeating thoughts, feelings and/or behaviors, and all other aspects of their life in which the problem is less severe or not of concern. The identification and amplification of general exceptions does not necessarily imply that the client is not holding irrational beliefs. We have found, however, that identifying and amplifying both rational exceptions and general exceptions often contributes to more effective problem-solving and symptom relief.
REBT⋖shows⋖[clients] that they have rational (self-helping) and irrational (self-defeating) beliefs. REBT is both therapeutic and preventive in that it holds that rational and irrational beliefs go together and that when clients have the latter (e.g., “I absolutely must perform well”), they also have the former (e.g., “I prefer to perform well, but it’s not the end of the world if I don’t, and I can still be reasonably happy”). (p. 58)
The clinical process of our integrative model (described in the next section) often includes both an educative phase and an application phase. During the educative phase, the client is introduced to the principles of REBT and is encouraged to begin conceptualizing clinical problems in terms of the ABC theory. During this phase, the client is also provided with instruction in disputing irrational beliefs and various other cognitive, emotive, and behavioral techniques. The application phase includes helping clients to identify and amplify both rational exceptions and general exceptions. We have set forth a reformulated expansion of the ABC theory, denoted as ABCDE, to account for the change process where D refers to Disputing irrational beliefs and E refers to identifying and amplifying Exceptions (rational and general).
In a similar vein, we understand our integrative model as including aspects of preferential REBT, general REBT, solution-focused conceptualizations and interventions, and virtually any other techniques that bring about effective change. We have found that a flexible clinical approach speaks to Paul’s (1967) cogent point that therapy is to be deemed as effective in relation to how it addresses the question of “what treatment by whom, is most effective for this individual, under what set of circumstances” (p. 117).
REBT⋖includes a reserve of other cognitive, emotive, and behavioral methods that may be useful for particular clients when its most popular methods are resisted by the client, therapist, or both. REBT practitioners are free to experiment with a wide variety of techniques, some of which may seem irrational⋖When all else fails, REBT therapists can use various techniques from other forms of therapy, including even some “irrational” techniques, to help clients who resist employing the “best” methods. (pp. 157–158)
Integrative Clinical Process
The following description of our model’s clinical process is meant to serve as a guide that inevitably requires detours (cf., O’Hanlon & Weiner-Davis, 1989). Because each client is unique, the descriptions might not account for the details that are distinctive to a particular case. In some cases, for example, we might choose to bypass the REBT elements of the model and, instead, follow a straightforward solution-focused approach. Nevertheless, our model often includes the following stages: (1) problem definition and goal setting, (2) disputing irrational beliefs and other techniques, (3) identifying and amplifying exceptions, (4) assigning homework and tasks, (5) identifying and amplifying exceptions derived from homework and tasks, and (6) re-evaluating the problem and goal.
Problem Defxinition and Goal Setting
The process of defining a problem may be started by simply asking the client, “What is the problem that brings you here today?” Therapists can also put the question in goal-setting terms by asking, “What would you like to accomplish through therapy?” As the client describes his or her problems and symptoms, the therapist begins to conceptualize the clinical presentation in terms of the ABC theory. For example, if a client were to state, “I feel anxiety in social situations and often avoid them,” the therapist would conceptualize the Activating event (A) as social situations, the emotional and behavioral Consequences (C) as anxiety and avoidance, and then attempt to illicit the irrational Beliefs (B) presumed to be largely contributing to the anxiety and avoidance; that is, “I must achieve outstandingly well in one or more important respects or I am an inadequate person!” The client is also introduced to the ABC theory at this stage and is encouraged to understand his or her problems in this mode. In particular, the client is persuaded to understand that Activating events (A) do not directly cause emotional and behavioral Consequences (C) but, rather, it is largely one’s irrational Beliefs (B) about Activating events (A) that are the main contributor. Furthermore, the client is helped to understand the critical difference between rational beliefs and irrational beliefs, how humans can simultaneously hold both rational beliefs and irrational beliefs, and how each contributes differently to emotional and behavioral Consequences (C).
In some cases, the therapist might deem it appropriate to bypass conceptualizing the problem in terms of REBT principles in order to avert creating resistance or to avoid other impediments to change. There also might be instances when the client presents a problem and goal that is particularly conducive to a straightforward solution-focused approach. Using a solution-focused approach in some cases might create a context for bringing about the minimalist, albeit significant, change that might otherwise not be realized had REBT procedures been used. In such cases, we usually look to the client for guidance in selecting a fitting problem definition and goal. Hence, it is crucial to learn how the client makes sense of the problem (i.e., what, if any, cause the client might attribute to the problem). Clients might attribute their problem to any number of various “causes,” including an event, a mental disorder, another person’s behavior, or a psychological construct. In a case involving a married woman, for example, the client attributed the problem to “codependency.” In keeping with a solution-focused perspective, the problem was conceptualized as “codependency/not codependency.” The problem definition stage involved obtaining a video description of what the client does when she is thinking, feeling, and acting codependently. Exceptions were then identified in the direction of change.
Disputing Irrational Beliefs and Other Techniques
Since cognition, emotion, and behavior are interactive and reciprocally related, we also encourage clients to dispute irrational beliefs in conjunction with various cognitive, emotive, and behavioral techniques. Ellis & Dryden (1990) have suggested that “cognitive change is often facilitated by behavioral change” (p. 173). Along similar lines, Ellis (1980) has suggested that “if people force themselves to act⋖differently, they frequently will bring about cognitive modification” (p. 332). Cognitive techniques include the use of coping self-statements where clients are encouraged to write down and repeat to themselves rational beliefs to supplement their disputation of irrational beliefs. A variety of psycho-educational are also used, including encouraging clients to read REBT self-help books and use REBT self-help forms. Emotive techniques include rational-emotive imagery and encouraging clients to dispute irrational beliefs in forceful, evocative, and dramatic ways (Ellis, 1985). Behavioral techniques include in vivo desensitization or exposure, and implosion (Ellis, 1985, 1999; Ellis & Dryden, 1990).
employ[s] the hypothetical-deductive method of science whereby⋖[clients] reformulate their absolutistic notions about the world into testable hypotheses, and⋖test these hypotheses. Those beliefs that can be reasonably and realistically supported with objective evidence will be kept and considered to be rational. Those beliefs that are unproven or are contradicted by existing evidence are given up. (p. 19)
We also employ a variety of practical methods aimed at helping clients change negative conditions in their lives; that is, Activating events (A). These methods might include teaching clients specific skills, such as parenting, budget planning, and problem-solving. These techniques, however, are usually employed along with the disputation method. Although we strive to help clients change negative Activating events (A), we often encourage them to first change their irrational beliefs about these circumstances since, it is assumed, that once clients are less emotionally and behaviorally disturbed, they will very often then be more adept in their problem-solving strategies (cf., Ellis, 1980; Ellis & Dryden, 1990).
Identifying and Amplifying Exceptions
If we have previously employed an REBT conceptualization when defining the problem, we usually begin this part of the clinical process by first seeking to identify rational exceptions, rather than general exceptions. It is reminded that rational exceptions refer to instances when, in the context of clinical disturbances, the client retains their preference (rational belief), yet does not escalate the preference into a demand (irrational belief). For example, the therapist might ask the client, “When has there been a time when you felt sad, but not depressed, about this situation?” This question is aimed at identifying those times when the client experienced an appropriate emotional Consequence (C) about a negative Activating event (A). In keeping with REBT theory, it is assumed that such instances are occasioned by rational beliefs, rather than irrational beliefs. Accordingly, the client would then be asked to recall their Belief (B) during the time when they felt sad, rather than depressed. Thus, the client might be asked a line of questioning in the direction of identifying corresponding rational beliefs; for example, “What were you telling yourself about the Activating event (A) when you felt only sad, but not depressed?” (and so on). In other cases, the therapist might first focus on identifying incidences of rational beliefs, rather than initially attempting to identify appropriate emotional and behavioral Consequences (C). So, the therapist might ask the client, “When has there been a time when you thought rationally about this situation?” and then proceed to identify the corresponding appropriate emotional and behavioral Consequences (C). In either case, the incidence of rational Beliefs (B) and corresponding appropriate emotional and behavioral Consequences (C) signify rational exceptions that are to be amplified (described below).
A rule of thumb when asking such questions is to use language that creates a context for identifying exceptions. For example, it is important to ask, “When has there been a time when you felt sad, but not depressed, about this situation?” rather than “Has there been a time when you felt sad, but not depressed, about this situation?” The latter is a yes-or-no question that leaves room for the client to respond negatively. The former carries with it a sense of expectancy that indeed there have been exceptions. Often there is a silent response because many clients are not accustomed to being asked at such an early stage in treatment about times when things are going better. This questioning is interventive as it produces a sudden shift in the client’s problem focus. The therapist should be comfortable with the silence and give the client time to digest this line of questioning.
If the client identifies exceptions, then proceed to amplify them. If the client states that there have been no exceptions, however, encourage the client to consider small differences. Clients can frequently recall exceptions when asked to consider small changes that have occurred. It has also been found that small changes often lead to bigger changes (cf., Erickson, 1980). Although it is difficult to imagine being less demanding—that is, you are either placing a demand (on yourself, someone else, or life conditions) or you are not—there are instances when small changes might represent rational exceptions. Consider, for example, that a client might be able to identify a time when they still felt significantly upset, but nevertheless less disturbed than usual. Further inquiry might reveal that in such cases the client did not hold an irrational belief and, as a result, was experiencing an appropriate, rather than inappropriate, emotional Consequence (C).
If rational exceptions are identified, the client is helped through various lines of questioning to amplify these exceptions. One of the main functions of amplifying exceptions is to help clients to identify the differences between the times when they have the problem and the times when they do not. An example of such questioning might be, “How did you make that happen?” O’Hanlon & Weiner-Davis (1989) have stated that “verbalizing⋖ [differences] produces clarity both for us and for our clients. Once our clients identify how they get good things to happen, they will know what it will take to continue in this vein” (p. 86). Questioning aimed at identifying such differences also reinforces REBT principles, including the differences between rational beliefs and irrational beliefs. Another purpose of the amplification process is to empower clients with a sense of self-efficacy. Questions aimed toward this end include, “What does this [i.e., the rational exceptions] say about you and your ability to deal with the problem?” and “What are the possibilities?” The former is aimed at eliciting a response to the effect, “I am capable of solving this problem” or “I am capable of thinking more rationally and not making myself disturbed.” The latter is aimed at ascribing a sense of hope, optimism, and determination in relation to the problem and goal.
Sometimes clinicians become frustrated when clients are unable, unwilling, or otherwise do not identify exceptions. The client might be so problem focused that it is necessary for the therapist to help them visualize what a solution would look like. Questions aimed at identifying potential rational exceptions might take the form of, “What will you be thinking when you are feeling sad, but not depressed?” This process is adapted from de Shazer’s (1978) Crystal Ball Technique, which involves encouraging clients to picture themselves in a future situation in which they are functioning satisfactorily. Molnar and de Shazer (1987) have noted that “the ‘Crystal Ball Technique’ came to be regarded as a precursor of a solution focus, in that it was an early attempt to systematically focus the client on solutions rather than on problems” (p. 350). In some cases, clients and counselors are unable to identify rational exceptions or potential rational exceptions. When this happens, the therapist may consider providing the client with more education in REBT principles or shifting to identifying general exceptions.
It should be remembered that general exceptions refer to any instance when the client has experienced some improvement in their problem, and all other aspects of their life when the problem is less severe or not of concern. The process of identifying general exceptions is essentially the same as those methods used in a straightforward solution-focused approach. General exceptions are sought in cases when REBT principles are bypassed during the problem definition stage, when the therapist and client are unable to identify rational exceptions, or as an adjunct to the process of identifying rational exceptions. Questions aimed at identifying general exceptions are designed to uncover virtually any instance of improvement or positive difference in relation to the problem.
Assigning Homework and Tasks
When REBT principles have been used in previous stages of treatment, homework and tasks are designed to help the client practice disputing irrational beliefs, and identify and amplify both rational exceptions and general exceptions. If REBT principles have not been used, then this stage aims to help clients identify and amplify general exceptions. In either case, at the outset of this stage, the therapist can help carry the momentum by summarizing what has been discussed thus far. The summary should include reviewing with the client the problem, goal, and exceptions that have been identified. It is also helpful to compliment the client at this time for taking the initiative to seek help and for his or her willingness to make positive changes.
Because you naturally and easily think crookedly and behave defeatingly, because you have a strong biological as well as sociological tendency to disturb yourself⋖there is normally no way, but hard work and practice ⋖to change yourself and to keep yourself less miserable and more functional. (Ellis, 1987, p. 111)
1. Client is told, “Between now and the next time, I would like you to continue to do more of the exceptions.” (If the client is able to define a problem and goal, and is able to identify exceptions.)
2. Client is told, “Between now and the next time, I would like you to observe for those times when it happens in your life (i.e., exceptions).” (If the client is able to define a problem and goal, is able to identify potential exceptions, but is not able to identify exceptions.)
3. Client is told, “Between now and the next time, I would like you to think about what you will be doing differently when the problem is improved.” (If the client is able to define a problem, and is not able to define a goal.)
These tasks and criteria are a parsimonious attempt at setting guidelines for the selection process. In some cases, it might be fitting to construct a different task or not to construct a task at all. In other cases, we might combine two or more tasks. We also frequently supplement tasks with other techniques, including in vivo desensitization, bibliotherapy, and writing exercises. In each case, it is critical for the tasks to make sense for the client and their situation. Accordingly, we make every effort to determine if the client agrees that the task is a meaningful activity given the problem and goal.
Identifying and Amplifying Exceptions Derived from Homework and Tasks
It is important for the therapist to demonstrate at the outset of the second and subsequent sessions that he or she remembers and is interested in what was previously discussed. Doing so helps both the client and the therapist remain focused. Accordingly, documentation that includes specific data corresponding to the stages of our model (including the problem, goal, and exceptions) is essential. The session can be started by summarizing what was discussed during the previous session and reminding the client of the task. Identifying exceptions derived from the task should be done in a manner similar to the previous session. As always, it is important to use language that creates an expectancy of change.
If exceptions are identified, these should be amplified in the manner discussed previously. After amplifying exceptions, we re-evaluate the problem (discussed below). If the client states, “I did not remember to do it [e.g., Task 1],” then avoid creating resistance and, instead, foster a cooperative approach by responding, “Okay. Let’s think about it now. When was there a time this past week when it happened in your life (i.e., exceptions)?” If the client reports that there were no exceptions, aim to identify small changes. If the client maintains that there were no exceptions, it may be necessary to discuss or reconstruct the problem which, in turn, might provoke the identification of exceptions. Often exceptions come out later in the session (i.e., the client might recall exceptions after he or she stated that there was none). In some cases, clients will be very problem focused at the start of the next session. They might assert that things got worse or they might have recently experienced a severely problematic situation (perhaps just before the session). When this happens, therapists can suggest to the client, “I am very interested in hearing about this, but I would first like to check on the task that we discussed at the end of the last session.” Most of the time, clients will agree to this. After inquiring about the task (and hopefully identifying and amplifying exceptions), the problem can be re-evaluated and, if needed reconstructed.
Re-evaluating the Problem and Goal
After evaluating the effectiveness of tasks, the problem and the goal are re-evaluated and, if necessary, redefined. During this stage, the client is helped to consider the extent to which progress or the results of homework and tasks amount to an attainment of the goal. If the treatment goal has been reached or the client has made significant progress in the direction of the goal, then it might be appropriate for the therapist to ask the client whether he or she thinks that further treatment is needed at this time. Discussing whether further treatment is needed maintains a focused approach and helps to curtail the incidence of drop outs. It is apparent that a large number of clients drop out of treatment after just a few sessions either by canceling or not showing for appointments. Ideally, we strive to reach a consensus with clients regarding the issue of when treatment is (and is no longer) needed.
If the client reports that the goal has been reached or sufficient progress has been made, yet additional sessions are needed, then subsequent treatment might be organized around building on the client’s gains. If the client has made significant progress and also claims that further treatment is needed, then perhaps the problem or goal has not yet been satisfactorily defined. The client may also indicate that the goal has been reached and that there is now a new problem and goal. In such cases, it is important to help the client reconstruct the problem and goal. It could be said that talking about a problem at different times necessarily produces a change in its definition (i.e., the words used and hence the meaning ascribed changes). The therapist can use this inevitability to work toward reconstructing more solvable problems. The goal might need to be more attainable, more general, more specific, or more relevant to the client’s problem.
A 73 year old married man presented with the problem of depression. He stated that he had been diagnosed with major depression two years ago following a myocardial infarction. He stated that he experienced limited improvement after trying several antidepressants. The client stated that since becoming depressed he seldom engaged in recreational or social activities and was anhedonic. The client stated that his goal was to become his “old self” again. The therapist considered that the client’s depression was, to some degree, endogenous insofar as it related to the myocardial infarction. The therapist also presumed, however, that psychological factors were related to the depression. In particular, the client reported feeling significantly guilty about his depressive condition. In REBT, the term secondary disturbance has been used to refer to the emotional disturbances that clients sometimes experience about their principal inappropriate emotional and behavioral Consequences (C) (Walen et al., 1992). In this case, the therapist understood the client’s secondary disturbance as an irrational Belief (B) about his depression (which was conceptualized as an Activating event [A] in itself) that in turn, resulted in an emotional Consequence (C) of guilt. The therapist provided REBT education to the client, including the ABC theory, and encouraged the client to conceptualize his problems accordingly. It was agreed that the client had secondary disturbance and, moreover, that his guilt feelings about his depression exacerbated his condition.
The client was also asked to describe, in behavioral terms, what being his old self was like. He stated that when he was his old self, he was very active, socialized frequently, and enjoyed activities of daily living. The client was able to identify an instance in the recent past when he did not feel guilty upon thinking about his depression but, instead, felt concerned (rational exception). The client also identified a few rare instances when he found that he was being his old self (general exception). The client maintained, however, that these exceptions were not significant. The client was then taught how to identify and dispute the irrational belief that was contributing to his secondary disturbance; that is, “I must not be depressed or else I am an inadequate person.” At the end of the first session, the client was asked to observe for times when he was able to successfully dispute this irrational belief. The client was also asked to observe for times when he found that he was being his old self.
At the start of the second session, the client smiled and stated, “I am my old self again!” He invited his wife to attend the second session and she confirmed that her husband had made significant progress during the past week. The therapist proceeded to ask the client and his wife to identify the many instances in the past week when he was being his old self. Various general exceptions to depression were identified, including the client’s initiating a card game one evening with a couple that he and his wife had previously socialized with on a regular basis. The client also identified progress he had made with regard to disputing the irrational belief that was identified in the first session (rational exception). During the second session, the client forcefully affirmed, “I am not an inadequate person because I have been depressed! I am an acceptable human being who is still the fine person I was before I became depressed!”
During the third session, held one week later, the client was encouraged to read an REBT self-help book. At the end of the third session, the client was asked to continue to do more of the exceptions. At the fourth session, held two weeks later, the client and his wife reported continued progress. During the fourth session, it was agreed that the client was being his old self again and that further sessions were not needed at this time. It was agreed that the client could schedule another session if he felt himself slipping away from being his old self. Three months later, the therapist made a telephonic follow-up. The client reported that he was still being his old self; that he seldom, if ever, felt guilty about his condition; and that he was feeling much less depressed. The client was again advised that he could schedule another session if he ever felt the need. The therapist never heard from the client again.
Many questions remain regarding the theory, research, and practice of this integrative model. It could be argued that at times the clinical applications are ostensibly similar to each of the models from which the integration has been developed. This is especially pertinent upon considering that Ellis (1996) has acknowledged that his clinical model allows for the inclusion of solution-focused techniques in cases when REBT’s preferred approaches are ineffective. We affirm, however, that our integration of REBT and solution-focused therapy is valuable because it affords therapists with a basis from which to combine these two models with conceptual clarity and consistency.
It is reaffirmed that integrating REBT and solution-focused therapy addresses the limitations of each model while enhancing their respective strengths. In the case example, the therapist used REBT principles to help the client dispute an irrational belief that was presumed to be significantly contributing to the problem. In addition, the therapist helped the client to identify and amplify general exceptions in keeping with a solution-focused approach. It follows that the integrative model is comprehensive in that it strives for both (a) REBT’s large scope of change and educative approach, and (b) solution-focused therapy’s emphasis on using the client’s language and striving for minimalist goals. In the case example, the therapist used the client’s language (i.e., old self) as an organizing metaphor. Using the client’s unique frame of reference is a hallmark of solution-focused therapy’s cooperative approach (de Shazer, 1984). Conversely, the therapist taught REBT principles to the client, which enhanced the change process.
The use of REBT principles within the integrative model also provides much needed content that is missing from the solution-focused approach. Like other models informed by a social constructionist perspective (e.g., Anderson & Goolishian, 1988), solution-focused therapy is to be considered a “process model” because its theory of problem formation and change, unlike traditional models, avoids imposing predetermined content (e.g., irrational beliefs) during the change process (Held, 1992). It is reminded that in solution-focused therapy, problems are conceptualized as the client’s “languaging” about problem/exception. Solution-focused therapy does not, however, specify what the problem/exception shall be. Process models like solution-focused therapy, as a result of their positing such general theories of problem formation, allow for the use of virtually any content that clients might bring to treatment. This preference to avert imposing predetermined content, however, can result in the therapist feeling less than grounded during the change process (Held, 1986). The integrative model addresses this limitation of process models by allowing for the use of REBT principles.
We recommend that future research focus on both qualitative and quantitative studies aimed at evaluating the effectiveness of this model. In addition, further investigations might focus on articulating the decision-making processes of clinicians for the selection of the various conceptualizations and interventions available in the integrative model. Such a study would address the question, for example, of when it is preferable to use a straightforward solution-focused approach, rather than a blend of REBT and solution-focused therapy. In a similar vein, Colaptino (1979) has considered a framework whereby therapists shift from one therapy approach to another on the basis of various factors, including the type of client or problem. According to Colapinto, “an ‘alternation’ pattern seems theoretically possible, but then a ‘second-order’ model will be needed whose function will be to prescribe the differential applicability of the two modes in specific situations” (1979, p. 439). More generally, then, research could focus on identifying the criteria from which therapists choose to shift between divergent therapies and the effects of the alternations.
Finally, it is reaffirmed that the integrative model set forth speaks to the call that has been made by various writers for convergence and rapprochement in our field. Indeed, the model holds promise for guiding the systematic development, refinement, and expansion of numerous divergent therapy models. Therapists can follow the process described in this article of invoking pertinent rationales for combining theories and techniques from different models. Such applications may be worthwhile endeavors so long as therapists recognize the importance of developing integrative models that are systematic and consistent.