A Solution-focused Approach to Rational-emotive Behavior Therapy - Toward a Theoretical Integration

8/9/2019 A Solution-focused Approach to Rational-emotive Behavior Therapy - Toward a Theoretical Integration

1/22

A SOLUTION-FOCUSED APPROACH

TO RATIONAL-EMOTIVE BEHAVIOR THERAPY: TOWARD A THEORETICAL

INTEGRATION

Jeffrey T. GutermanJames Rudes

Barry University, USA

ABSTRACT: A theoretical integration of rational emotive behavior therapy(REBT) and solution-focused therapy is described. It is suggested that theintegrative conceptualization underscores these models’ complementaryaspects by addressing the limitations of each and enhancing their respective

strengths. The clinical theory and process of the integrative model isexplicated along with a case example. Directions for future theory building,research, and practice are considered.

KEY WORDS: REBT; solution-focused therapy; integration.

In the last quarter century, there has been an increasing literatureregarding the merits and limitations of integrating diverse therapy

models. It has been suggested that the movement toward integrationis reflective of a trend that recognizes the restraints of adhering to asingle-based clinical theory and the benefits of rapprochement, dia-logue, and convergence between schools (Norcross & Goldfried, 1992;Safran & Messer, 1997). Proponents of the integrative movement rec-ognize that no single model is adequate to account for all clients andproblems. For example, Liddle (1982) has suggested that ‘‘the ten-dency toward integrationism seems related…to our frustration with

the limits of any one approach or perspective’’ (p. 247). As a result,

Address correspondence to Jeffrey T. Guterman, Barry University, 11300 NE 2 Avenue, AdrianDominican School of Education, Counseling Program, Powers Building, Miami Shores, FL 33161–6695, USA; e-mail: [email protected]

Journal of Rational-Emotive & Cognitive-Behavior Therapy, Vol. 23, No. 3, Fall 2005 ( 2005)

DOI: 10.1007/s10942-005-0012-z

223 2005 Springer Science+Business Media, Inc.


2/22

numerous integrative models have been set forth in which disparatetheories 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 sometheorists, however, with regard to the meanings of some of the pre-vailing terms used to describe integrative models. For example, manywriters have agreed that theoretical integration refers to combiningtwo or more distinct theories and thereby producing a new, superor-dinate clinical framework (e.g., Norcross, 1990; Safran & Messer,1997). Various theoretical integrations have been proposed. In thisarticle, we present an integration of Ellis’s (1996, 1999, 2001)rational emotive behavior therapy (REBT) and the solution-focusedtherapy model developed by de Shazer (1985, 1988, 1991) and deShazer et al. (1986). This model describes and explains some of ourmost recent work with clients.

In REBT, clinical problems are conceptualized as largely the resultof irrational beliefs, which consist of demands that humans escalatefrom their healthy preferences (Ellis, 1996). The primary goal inREBT is to help clients replace irrational beliefs with rational beliefsthrough various cognitive, emotive, and behavioral techniques. In

contrast, solution-focused therapy conceptualizes problems in termsof the client’s talk or ‘‘languaging’’ about problems and the necessaryexistence (either actual or potential) of exceptions (i.e., times whenthe problem is not happening); in other words, problem/exception (deShazer, 1991; de Shazer et al., 1986). Solution-focused therapy tendsto emphasize clients’ existing strengths, rather than their deficits,and often focuses on minimalist goals. REBT, on the other hand, pla-ces more emphasis on deficits (i.e., irrational beliefs) and seeks a

large scope of change by helping clients adopt a rational philosophyof life. Despite these differences, leading proponents of REBT andsolution-focused therapy have suggested that there is significantoverlap between these models and, moreover, at times their pre-sumed differences might be indiscernible (e.g., Ellis, 1996; Molnar &de Shazer, 1987).

Petzold (1981) has proposed an integration of the clinicalapproaches 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 thatthere is a paucity of writing on the topic of integrating REBT andsolution-focused therapy. In this article, the position is taken thatthere is a bonus to be attained by systematically integrating the

224 Journal of Rational-Emotive & Cognitive-Behavior Therapy


3/22

clinical theories of REBT and solution-focused therapy. In particular,it is suggested that an integrative conceptualization underscoresthese models’ complementary aspects; that is, the integration com-

pensates for their respective weaknesses and enhances the strengthsof each individual model. The result is a new clinical approach that ismore comprehensive than either of the singular models. The organi-zation of this article is as follows. First, the clinical theories of REBTand solution-focused therapy are described. Next, the integrative clin-ical theory is set forth. The clinical process of the integrative model isthen explicated along with a case example. Finally, directions forfuture theory building, research, and practice are considered.

CLINICAL THEORIES

Rational Emotive Behavior Therapy

Ellis (1988) has suggested that ‘‘you can figure out by sheer logicthat if you were only…to stay with your desires and preferences, andif 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 funda-mental principle, namely, that emotional and behavioral disturbanceis largely caused by demandingness (Ellis, 1962, 1988, 1996, 2001).REBT’s theory describes the processes whereby humans createirrational (i.e., self-defeating) philosophies and then indoctrinatethemselves with these ideas. In addition, REBT contends thathumans are taught irrational philosophies and frequently internalize

these ideas through persistent self-indoctrinations. According toREBT, humans make themselves disturbed by thenceforth bringingirrational philosophies to situations in their lives.

REBT theory is specified further by way of its distinction betweenrational beliefs and irrational beliefs. According to REBT, rationalbeliefs are evaluative cognitions that are nonabsolute and take theform of preferences, desires, and wishes (Ellis, 1962, 1996; Ellis &Dryden, 1990). Ellis and Dryden (1990) have suggested that rationalbeliefs are relative and do not interfere with the attainment of basicgoals. Irrational beliefs, on the other hand, tend to be absolute,dogmatic, and demanding and take the form of musts, shoulds, andoughts (Ellis, 1962, 1996). When humans hold irrational beliefsabout negative events in their lives, these generally correspond to

Jeffrey T. Guterman and James Rudes 225


4/22

self-defeating (also referred to as inappropriate) emotions and behav-iors (e.g., depression, anxiety, addiction) that usually block one fromworking toward their goals (Ellis, 1996). Rational beliefs about nega-

tive events tend to result in self-helping (also referred to as appropri-ate) emotions and behaviors (e.g., sadness, concern, annoyance) thataids one in working toward their goals (Ellis, 1996).

Ellis (1962) originally identified twelve irrational beliefs, which, hetheorized, are mainly responsible for creating disturbances. Subse-quently, Ellis (1999) has condensed this original list to comprisethree core irrational beliefs:

(a) ‘‘I must achieve outstandingly well in one or more importantrespects or I am an inadequate person!’’ (b) ‘‘Other people musttreat me fairly and well or they are bad people!’’ (c) ‘‘Conditionsmust be favorable or else my life is rotten and I can’t stand it!’’(p. 155)

REBT’s ABC theory explains quite simply the processes whereby hu-mans become emotionally and behaviorally disturbed (Ellis, 1962,1988, 1996). A stands for Activating events. B stands for Beliefs. Cstands for emotional and behavioral Consequences. REBT holds that

Activating events (A) do not directly cause emotional and behavioralConsequences (C). Instead, it is one’s Beliefs (B) about Activatingevents (A) that contribute most to emotional and behavioral Conse-quences (C). REBT’s ABC theory posits that appropriate emotional andbehavioral Consequences (C) are largely caused by rational Beliefs (B)about Activating events (A). Conversely, inappropriate emotional andbehavioral 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 emotionaland behavioral problems so that they can work toward their goals in aneffective and efficient manner (Ellis, 1996). The course of REBT in-cludes introducing to clients the principles of REBT, and helping themuse various cognitive, emotive, and behavioral techniques aimed atdisputing irrational beliefs and modifying dysfunctional feelings andbehaviors. The disputation method, REBT’s principal technique, hasbeen 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 avariety of behavioral and emotive technique aimed at helping clientschange their self-defeating thoughts, feelings, and behaviors.



5/22

Solution-focused Therapy

The clinical theory of solution-focused counseling is informed by a

social constructionist position that holds that there are no clinicalproblems independent of the social interchange that occurs betweenclinicians and clients (de Shazer, 1991). Accordingly, clinical prob-lems are co-created in language between therapists and clients. DeShazer (1991) has noted, however, that the notion of problem neces-sarily implies the existence of ‘‘non-problem’’ or exception, that is,

times when the…problem does not happen even though the clienthas reason to expect it to happen, and, of course, the space be-

tween problem and non-problem or the areas of life in which theproblem/non-problem is not an issue and is not of concern to theclient. (p. 83)

In solution-focused therapy, the notion of problem has within it theseeds 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 amplify-

ing exceptions. Clinicians use interventive questions to help clientsidentify exceptions; for example, ‘‘When has there been a time whenyou have coped better with this problem?’’ Exceptions may be ampli-fied by encouraging clients to do more of the behaviors that have ledthem to solve the problem in the past, to observe times when theyare dealing better with the problem, or to ascribe meaning to excep-tions. The criterion for problem resolution in solution-focused therapyis that the presenting problem is sufficiently improved or sufficient

progress has made been made in the direction of the goal.The process of solution-focused therapy usually involves five

stages: (1) constructing a problem and goal, (2) identifying and ampli-fying exceptions, (3) interventions or tasks designed to identify andamplify exceptions, (4) evaluating the effectiveness of interventions,and (5) re-evaluating the problem and goal. In solution-focused ther-apy, 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 problemas frequent arguing with their spouse, the problem would be concep-tualized as arguing with my spouse/not arguing with my spouse. Inmany cases, problem resolution is attributed to the client’s own view



6/22

that he or she is no longer experiencing the problem. This might berelated to an increase in exceptions or an increase in the client’sawareness of exceptions. In each case, however, change is facilitated

by the client’s ascribing significant meaning to the exceptions. As deShazer (1991) has suggested, ‘‘for the client, the problem is seen asprimary (and the exceptions, if seen at all, are seen as secondary),while for therapists the exceptions are seen as primary; the interven-tions are meant to help clients make a similar inversion, which willlead to the development of a solution’’ (p. 58).

Integrative Clinical Theory

Our integrative theory begins with the assumption that clientshave tendencies to think both rationally and irrationally. When indi-viduals stay only with their rational beliefs (i.e., when they do notescalate rational beliefs to irrational beliefs), they tend to experienceappropriate emotional and behavioral Consequences (C). When indi-viduals escalate rational beliefs to irrational beliefs, this tends to re-sult in inappropriate emotional and behavioral Consequences (C).Furthermore, when individuals experience inappropriate emotional

and behavioral Consequences (C), they tend to simultaneously holdrational beliefs and irrational beliefs. Ellis (1997) has described thislatter aspect of REBT as follows:

REBT…shows…[clients] that they have rational (self-helping) andirrational (self-defeating) beliefs. REBT is both therapeutic andpreventive in that it holds that rational and irrational beliefs gotogether and that when clients have the latter (e.g., ‘‘I absolutelymust 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 canstill be reasonably happy’’). (p. 58)

It follows that disturbance is to be understood in terms of the coex-istence of rational beliefs and irrational beliefs. The change processentails helping the client replace irrational beliefs with rational be-liefs by identifying and amplifying rational exceptions: instanceswhen, in the context of clinical disturbances, the client retains theirpreference (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 theclient has experienced some improvement in their self-defeatingthoughts, feelings and/or behaviors, and all other aspects of their life



7/22

in which the problem is less severe or not of concern. The identifica-tion and amplification of general exceptions does not necessarily im-ply that the client is not holding irrational beliefs. We have found,

however, that identifying and amplifying both rational exceptionsand general exceptions often contributes to more effective problem-solving and symptom relief.

The clinical process of our integrative model (described in the nextsection) often includes both an educative phase and an applicationphase. During the educative phase, the client is introduced to theprinciples of REBT and is encouraged to begin conceptualizing clini-cal problems in terms of the ABC theory. During this phase, the cli-ent is also provided with instruction in disputing irrational beliefsand various other cognitive, emotive, and behavioral techniques. Theapplication phase includes helping clients to identify and amplifyboth rational exceptions and general exceptions. We have set forth areformulated expansion of the ABC theory, denoted as ABCDE, to ac-count for the change process where D refers to Disputing irrationalbeliefs and E refers to identifying and amplifying Exceptions (ra-tional and general).

We now briefly describe Ellis’s (1977, 1980, 1996, 2001) distinction

between preferential REBT and general REBT in order to offer arationale for our use of various techniques and goals of treatmentwithin the integrative model. According to Ellis (1977), preferentialREBT (also referred to as elegant REBT) involves helping clientsmake a profound philosophic change whereby core irrational beliefsare replaced with rational beliefs. This approach is considered prefer-ential because it prepares clients to deal effectively with both currentand future events by ascribing rational, rather than irrational, beliefs

and thereby avert self-defeating emotions and behaviors. GeneralREBT, on the other hand, refers to the use of alternatives to the dis-putation method, including many of the techniques used in Beck’s(1976) cognitive therapy and Meichenbaum’s (1977) cognitive-behav-ior therapy. Ellis (1996) has pointed out that although his first choiceis to use preferential REBT, he does not rigidly hold to this treat-ment in cases where it is assessed that the client is not amenable tosuch an approach; where there is significant resistance to such meth-

ods; or where such an application might otherwise impede progress.Ellis (1999) has also advocated the use, in some cases, of techniquesthat run counter to some of REBT’s main principles:



8/22

REBT…includes a reserve of other cognitive, emotive, and behav-ioral methods that may be useful for particular clients when itsmost popular methods are resisted by the client, therapist, orboth. REBT practitioners are free to experiment with a wide vari-ety of techniques, some of which may seem irrational…When allelse fails, REBT therapists can use various techniques from otherforms of therapy, including even some ‘‘irrational’’ techniques, tohelp clients who resist employing the ‘‘best’’ methods. (pp. 157–158)

In a similar vein, we understand our integrative model as includ-ing aspects of preferential REBT, general REBT, solution-focusedconceptualizations and interventions, and virtually any other tech-

niques that bring about effective change. We have found that a flexi-ble clinical approach speaks to Paul’s (1967) cogent point thattherapy is to be deemed as effective in relation to how it addressesthe question of ‘‘what treatment by whom, is most effective for thisindividual, under what set of circumstances’’ (p. 117).

INTEGRATIVE CLINICAL PROCESS

The following description of our model’s clinical process is meant toserve as a guide that inevitably requires detours (cf., O’Hanlon &Weiner-Davis, 1989). Because each client is unique, the descriptionsmight not account for the details that are distinctive to a particularcase. In some cases, for example, we might choose to bypass theREBT elements of the model and, instead, follow a straightforwardsolution-focused approach. Nevertheless, our model often includes thefollowing stages: (1) problem definition and goal setting, (2) disputingirrational beliefs and other techniques, (3) identifying and amplifyingexceptions, (4) assigning homework and tasks, (5) identifying andamplifying exceptions derived from homework and tasks, and (6)re-evaluating the problem and goal.

Problem Definition 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?’’ Thera-pists can also put the question in goal-setting terms by asking, ‘‘Whatwould you like to accomplish through therapy?’’ As the clientdescribes his or her problems and symptoms, the therapist begins to



9/22

conceptualize the clinical presentation in terms of the ABC theory.For example, if a client were to state, ‘‘I feel anxiety in social situa-tions and often avoid them,’’ the therapist would conceptualize the

Activating event (A) as social situations, the emotional and behav-ioral Consequences (C) as anxiety and avoidance, and then attemptto illicit the irrational Beliefs (B) presumed to be largely contributingto the anxiety and avoidance; that is, ‘‘I must achieve outstandinglywell in one or more important respects or I am an inadequate per-son!’’ The client is also introduced to the ABC theory at this stageand is encouraged to understand his or her problems in this mode. Inparticular, the client is persuaded to understand that Activatingevents (A) do not directly cause emotional and behavioral Conse-quences (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 betweenrational beliefs and irrational beliefs, how humans can simultaneouslyhold both rational beliefs and irrational beliefs, and how each contrib-utes differently to emotional and behavioral Consequences (C).

In some cases, the therapist might deem it appropriate to bypassconceptualizing 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 problemand goal that is particularly conducive to a straightforward solution-focused approach. Using a solution-focused approach in some casesmight create a context for bringing about the minimalist, albeit sig-nificant, change that might otherwise not be realized had REBT pro-cedures been used. In such cases, we usually look to the client forguidance 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). Clientsmight attribute their problem to any number of various ‘‘causes,’’including an event, a mental disorder, another person’s behavior, or apsychological construct. In a case involving a married woman, forexample, the client attributed the problem to ‘‘codependency.’’ Inkeeping with a solution-focused perspective, the problem was concep-tualized as ‘‘codependency/not codependency.’’ The problem definition

stage involved obtaining a video description of what the client doeswhen she is thinking, feeling, and acting codependently. Exceptionswere then identified in the direction of change.



10/22

Disputing Irrational Beliefs and Other Techniques

After defining the problem in terms of the ABC theory, clients are

instructed to use the disputation method, which entails identifyingand challenging irrational beliefs. Walen, DiGiuseppe, and Dryden(1992) have described the disputation method as a process wherebythe validity and utility of irrational beliefs are questioned. The aim of the disputation method is to help clients internalize a new, rationalbelief system, which in turn, may be attached to future Activatingevents (A). Ellis and Yeager (1989) have described disputation as atechnique that

employ[s] the hypothetical-deductive method of sciencewhereby…[clients] reformulate their absolutistic notions aboutthe world into testable hypotheses, and…test these hypotheses.Those beliefs that can be reasonably and realistically supportedwith objective evidence will be kept and considered to be rational.Those beliefs that are unproven or are contradicted by existingevidence are given up. (p. 19)

Since cognition, emotion, and behavior are interactive and recipro-

cally related, we also encourage clients to dispute irrational beliefs inconjunction with various cognitive, emotive, and behavioral tech-niques. Ellis & Dryden (1990) have suggested that ‘‘cognitive changeis often facilitated by behavioral change’’ (p. 173). Along similar lines,Ellis (1980) has suggested that ‘‘if people force themselves to act…dif-ferently, they frequently will bring about cognitive modification’’ (p.332). Cognitive techniques include the use of coping self-statementswhere 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 encouragingclients to read REBT self-help books and use REBT self-help forms.Emotive techniques include rational-emotive imagery and encourag-ing clients to dispute irrational beliefs in forceful, evocative, and dra-matic ways (Ellis, 1985). Behavioral techniques include in vivodesensitization or exposure, and implosion (Ellis, 1985, 1999; Ellis &Dryden, 1990).

We also employ a variety of practical methods aimed at helping cli-

ents change negative conditions in their lives; that is, Activatingevents (A). These methods might include teaching clients specificskills, such as parenting, budget planning, and problem-solving.These techniques, however, are usually employed along with the



11/22

disputation method. Although we strive to help clients change nega-tive Activating events (A), we often encourage them to first changetheir 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-solvingstrategies (cf., Ellis, 1980; Ellis & Dryden, 1990).

Identifying and Amplifying Exceptions

If we have previously employed an REBT conceptualization whendefining the problem, we usually begin this part of the clinical pro-cess by first seeking to identify rational exceptions, rather than gen-eral exceptions. It is reminded that rational exceptions refer toinstances when, in the context of clinical disturbances, the client re-tains their preference (rational belief), yet does not escalate the pref-erence into a demand (irrational belief). For example, the therapistmight ask the client, ‘‘When has there been a time when you felt sad,but not depressed, about this situation?’’ This question is aimed atidentifying those times when the client experienced an appropriateemotional Consequence (C) about a negative Activating event (A). In

keeping with REBT theory, it is assumed that such instances are oc-casioned by rational beliefs, rather than irrational beliefs. Accord-ingly, the client would then be asked to recall their Belief (B) duringthe time when they felt sad, rather than depressed. Thus, the clientmight be asked a line of questioning in the direction of identifyingcorresponding rational beliefs; for example, ‘‘What were you tellingyourself about the Activating event (A) when you felt only sad, butnot depressed?’’ (and so on). In other cases, the therapist might first

focus on identifying incidences of rational beliefs, rather than ini-tially attempting to identify appropriate emotional and behavioralConsequences (C). So, the therapist might ask the client, ‘‘When hasthere been a time when you thought rationally about this situation?’’and then proceed to identify the corresponding appropriate emotionaland behavioral Consequences (C). In either case, the incidence of ra-tional Beliefs (B) and corresponding appropriate emotional andbehavioral Consequences (C) signify rational exceptions that are to beamplified (described below).

A rule of thumb when asking such questions is to use languagethat creates a context for identifying exceptions. For example, it isimportant to ask, ‘‘When has there been a time when you felt sad,but not depressed, about this situation?’’ rather than ‘‘Has there been



12/22

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 torespond negatively. The former carries with it a sense of expectancy

that indeed there have been exceptions. Often there is a silent re-sponse because many clients are not accustomed to being asked atsuch an early stage in treatment about times when things are goingbetter. This questioning is interventive as it produces a sudden shiftin the client’s problem focus. The therapist should be comfortablewith the silence and give the client time to digest this line of ques-tioning.

If the client identifies exceptions, then proceed to amplify them. If the client states that there have been no exceptions, however, encour-age the client to consider small differences. Clients can frequently re-call exceptions when asked to consider small changes that haveoccurred. It has also been found that small changes often lead to big-ger changes (cf., Erickson, 1980). Although it is difficult to imaginebeing less demanding—that is, you are either placing a demand (onyourself, someone else, or life conditions) or you are not—there areinstances 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 dis-turbed than usual. Further inquiry might reveal that in such casesthe client did not hold an irrational belief and, as a result, was expe-riencing an appropriate, rather than inappropriate, emotional Conse-quence (C).

If rational exceptions are identified, the client is helped throughvarious lines of questioning to amplify these exceptions. One of themain functions of amplifying exceptions is to help clients to identify

the differences between the times when they have the problem andthe times when they do not. An example of such questioning mightbe, ‘‘How did you make that happen?’’ O’Hanlon & Weiner-Davis(1989) have stated that ‘‘verbalizing… [differences] produces clarityboth for us and for our clients. Once our clients identify how they getgood things to happen, they will know what it will take to continuein this vein’’ (p. 86). Questioning aimed at identifying such differ-ences also reinforces REBT principles, including the differences be-

tween rational beliefs and irrational beliefs. Another purpose of theamplification process is to empower clients with a sense of self-effi-cacy. Questions aimed toward this end include, ‘‘What does this [i.e.,the rational exceptions] say about you and your ability to deal withthe problem?’’ and ‘‘What are the possibilities?’’ The former is aimed



13/22

at eliciting a response to the effect, ‘‘I am capable of solving thisproblem’’ or ‘‘I am capable of thinking more rationally and not mak-ing myself disturbed.’’ The latter is aimed at ascribing a sense of

hope, optimism, and determination in relation to the problem andgoal.

Sometimes clinicians become frustrated when clients are unable,unwilling, or otherwise do not identify exceptions. The client mightbe so problem focused that it is necessary for the therapist to helpthem visualize what a solution would look like. Questions aimed atidentifying potential rational exceptions might take the form of,‘‘What will you be thinking when you are feeling sad, but not de-pressed?’’ This process is adapted from de Shazer’s (1978) CrystalBall Technique, which involves encouraging clients to picture them-selves in a future situation in which they are functioning satisfactor-ily. Molnar and de Shazer (1987) have noted that ‘‘the ‘Crystal BallTechnique’ came to be regarded as a precursor of a solution focus, inthat it was an early attempt to systematically focus the client onsolutions rather than on problems’’ (p. 350). In some cases, clientsand counselors are unable to identify rational exceptions or potentialrational exceptions. When this happens, the therapist may consider

providing the client with more education in REBT principles or shift-ing to identifying general exceptions.

It should be remembered that general exceptions refer to anyinstance when the client has experienced some improvement in theirproblem, and all other aspects of their life when the problem is lesssevere or not of concern. The process of identifying general exceptionsis essentially the same as those methods used in a straightforwardsolution-focused approach. General exceptions are sought in cases

when REBT principles are bypassed during the problem definitionstage, when the therapist and client are unable to identify rationalexceptions, or as an adjunct to the process of identifying rationalexceptions. Questions aimed at identifying general exceptions aredesigned to uncover virtually any instance of improvement or positivedifference in relation to the problem.

Assigning Homework and Tasks

After identifying and amplifying exceptions, the question arises asto what extent the exceptions represent an attainment of the treat-ment goal; in other words, the degree to which the identification andamplification of exceptions have bridged the gap between the problem



14/22

and the goal. In some cases, the therapist and/or the client mightconsider that further sessions are not required to achieve the goal. Inother cases, the goal might not have been fully reached, but it is

agreed that the client has displayed sufficient movement in directionof the goal, making further sessions unnecessary. At this point in theprocess, therapists proceed to the stage of re-evaluating the problemand goal (described below). During the first session, however, it isusually agreed that further sessions are needed because more pro-gress is required. This is particularly relevant to the most importantinsight that REBT emphasizes:

Because you naturally and easily think crookedly and behave def-eatingly, because you have a strong biological as well as sociologi-cal tendency to disturb yourself …there is normally no way, buthard work and practice …to change yourself and to keep yourself less miserable and more functional. (Ellis, 1987, p. 111)

When REBT principles have been used in previous stages of treat-ment, homework and tasks are designed to help the client practicedisputing irrational beliefs, and identify and amplify both rationalexceptions and general exceptions. If REBT principles have not been

used, then this stage aims to help clients identify and amplify gen-eral exceptions. In either case, at the outset of this stage, the thera-pist can help carry the momentum by summarizing what has beendiscussed thus far. The summary should include reviewing with theclient the problem, goal, and exceptions that have been identified. Itis also helpful to compliment the client at this time for taking the ini-tiative to seek help and for his or her willingness to make positivechanges.

If the client is able to identify exceptions (rational or general), thentasks are usually organized around encouraging the client to do moreof the same. If the client is not able to identify exceptions, then tasksare designed to observe and build on the incidences of exceptions.Following is a list of three tasks that we most often use with clientsand the corresponding criterion that generally guides our selection of the task. These tasks have been adapted from those developed fromMolnar and de Shazer (1987) and address instances when the clinical

focus is on rational exceptions, general exceptions, or both.

Task 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.)



15/22


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 identifyexceptions.)


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 settingguidelines 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 othercases, we might combine two or more tasks. We also frequently sup-plement tasks with other techniques, including in vivo desensitiza-tion, bibliotherapy, and writing exercises. In each case, it is criticalfor the tasks to make sense for the client and their situation. Accord-ingly, we make every effort to determine if the client agrees that thetask is a meaningful activity given the problem and goal.

Identifying and Amplifying Exceptions Derived from Homeworkand Tasks

It is important for the therapist to demonstrate at the outset of thesecond and subsequent sessions that he or she remembers and isinterested in what was previously discussed. Doing so helps both theclient and the therapist remain focused. Accordingly, documentationthat 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 previ-ous session and reminding the client of the task. Identifying excep-tions derived from the task should be done in a manner similar tothe previous session. As always, it is important to use language thatcreates an expectancy of change.

If exceptions are identified, these should be amplified in the mannerdiscussed previously. After amplifying exceptions, we re-evaluate theproblem (discussed below). If the client states, ‘‘I did not remember to

do it [e.g., Task 1],’’ then avoid creating resistance and, instead, fostera 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,



16/22

aim to identify small changes. If the client maintains that there wereno exceptions, it may be necessary to discuss or reconstruct the prob-lem which, in turn, might provoke the identification of exceptions.

Often exceptions come out later in the session (i.e., the client mightrecall exceptions after he or she stated that there was none). In somecases, clients will be very problem focused at the start of the nextsession. They might assert that things got worse or they might haverecently experienced a severely problematic situation (perhaps justbefore the session). When this happens, therapists can suggest to theclient, ‘‘I am very interested in hearing about this, but I would first liketo 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 thetask (and hopefully identifying and amplifying exceptions), the prob-lem can be re-evaluated and, if needed reconstructed.

Re-evaluating the Problem and Goal

After evaluating the effectiveness of tasks, the problem and thegoal are re-evaluated and, if necessary, redefined. During this stage,the client is helped to consider the extent to which progress or the re-

sults of homework and tasks amount to an attainment of the goal. If the treatment goal has been reached or the client has made signifi-cant progress in the direction of the goal, then it might be appropri-ate for the therapist to ask the client whether he or she thinks thatfurther treatment is needed at this time. Discussing whether furthertreatment is needed maintains a focused approach and helps to cur-tail 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 can-

celing or not showing for appointments. Ideally, we strive to reach aconsensus with clients regarding the issue of when treatment is (andis no longer) needed.

If the client reports that the goal has been reached or sufficientprogress has been made, yet additional sessions are needed, thensubsequent treatment might be organized around building on the cli-ent’s gains. If the client has made significant progress and alsoclaims that further treatment is needed, then perhaps the problem orgoal has not yet been satisfactorily defined. The client may also indi-cate that the goal has been reached and that there is now a newproblem and goal. In such cases, it is important to help the clientreconstruct the problem and goal. It could be said that talking abouta problem at different times necessarily produces a change in its defi-



17/22

nition (i.e., the words used and hence the meaning ascribed changes).The therapist can use this inevitability to work toward reconstructingmore solvable problems. The goal might need to be more attainable,

more general, more specific, or more relevant to the client’s problem.

CASE EXAMPLE

A 73 year old married man presented with the problem of depres-sion. He stated that he had been diagnosed with major depressiontwo years ago following a myocardial infarction. He stated that heexperienced limited improvement after trying several antidepres-sants. The client stated that since becoming depressed he seldom en-gaged in recreational or social activities and was anhedonic. Theclient stated that his goal was to become his ‘‘old self’’ again. Thetherapist considered that the client’s depression was, to some degree,endogenous insofar as it related to the myocardial infarction. Thetherapist also presumed, however, that psychological factors wererelated to the depression. In particular, the client reported feelingsignificantly guilty about his depressive condition. In REBT, the term

secondary disturbance has been used to refer to the emotional distur-bances that clients sometimes experience about their principal inap-propriate emotional and behavioral Consequences (C) (Walen et al.,1992). In this case, the therapist understood the client’s secondarydisturbance as an irrational Belief (B) about his depression (whichwas conceptualized as an Activating event [A] in itself) that in turn,resulted in an emotional Consequence (C) of guilt. The therapist pro-vided REBT education to the client, including the ABC theory, and

encouraged the client to conceptualize his problems accordingly. Itwas 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, whatbeing 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 recentpast when he did not feel guilty upon thinking about his depressionbut, instead, felt concerned (rational exception). The client also iden-tified a few rare instances when he found that he was being his oldself (general exception). The client maintained, however, that theseexceptions were not significant. The client was then taught how toidentify and dispute the irrational belief that was contributing to his



18/22


19/22

upon considering that Ellis (1996) has acknowledged that his clinicalmodel allows for the inclusion of solution-focused techniques in caseswhen REBT’s preferred approaches are ineffective. We affirm, how-

ever, that our integration of REBT and solution-focused therapy isvaluable because it affords therapists with a basis from which tocombine these two models with conceptual clarity and consistency.

It is reaffirmed that integrating REBT and solution-focused ther-apy addresses the limitations of each model while enhancing theirrespective strengths. In the case example, the therapist used REBTprinciples to help the client dispute an irrational belief that was pre-sumed to be significantly contributing to the problem. In addition,the therapist helped the client to identify and amplify general excep-tions in keeping with a solution-focused approach. It follows that theintegrative model is comprehensive in that it strives for both (a)REBT’s large scope of change and educative approach, and (b) solu-tion-focused therapy’s emphasis on using the client’s language andstriving for minimalist goals. In the case example, the therapist usedthe client’s language (i.e., old self) as an organizing metaphor. Usingthe 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 enhancedthe change process.

The use of REBT principles within the integrative model also pro-vides much needed content that is missing from the solution-focusedapproach. Like other models informed by a social constructionist per-spective (e.g., Anderson & Goolishian, 1988), solution-focused therapyis to be considered a ‘‘process model’’ because its theory of problemformation and change, unlike traditional models, avoids imposing

predetermined content (e.g., irrational beliefs) during the change pro-cess (Held, 1992). It is reminded that in solution-focused therapy,problems are conceptualized as the client’s ‘‘languaging’’ about prob-lem/exception. Solution-focused therapy does not, however, specifywhat 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 cli-ents might bring to treatment. This preference to avert imposing pre-

determined content, however, can result in the therapist feeling lessthan grounded during the change process (Held, 1986). The integra-tive model addresses this limitation of process models by allowing forthe use of REBT principles.



20/22


21/22

de Shazer, S. (1984). The death of resistance. Family Process, 23, 11–17.de Shazer, S. (1985). Keys to solution in brief therapy. New York: Norton.de Shazer, S. (1988). Investigating solutions in brief therapy. New York:

Norton.de Shazer, S. (1991). Putting difference to work. New York: Norton.de Shazer, S., Berg, I. K., Lipchik, E., Nunnally, E., Molnar, E., Gingerich, K.,

& Weiner-Davis, M. (1986). Brief therapy: Focused solution development. Family Process, 25, 207–222.

Ellis, A. (1962). Reason and emotion in psychotherapy. Secaucus, NJ: LyleStuart.

Ellis, A. (1977). Rejoinder: Elegant and inelegant RET. Counseling Psychol-ogist, 7 , 73–82.

Ellis, A. (1980). Rational-emotive therapy and cognitive-behavior therapy:Similarities and differences. Cognitive Therapy and Research, 4, 325–340.

Ellis, A. (1985). Overcoming resistance: Rational-emotive therapy with difficultclients. New York: Springer.

Ellis, A. (1987). The evolution of rational-emotive therapy (RET) and cognitivebehavior therapy (CBT). In J. K. Zeig (Ed.), The evolution of psychother-apy (pp. 107–125). New York: Brunner/Mazel.

Ellis, A. (1988). How to stubbornly refuse to make yourself miserable aboutanything—yes anything! Secaucus, NJ: Lyle Stuart.

Ellis, A. (1996). Better, deeper, and more enduring brief therapy: The rational emotive behavior therapy approach. New York: Taylor and Francis.

Ellis, A. (1997). Response to Jeffrey T. Guterman’s response to my critique of social constructivism in mental health counseling. Journal of Mental Health Counseling, 19, 57–63.

Ellis, A. (1999). Why rational-emotive therapy to rational emotive behaviortherapy? Psychotherapy, 36, 154–159.

Ellis, A. (2001). Overcoming destructive beliefs, feelings, and behaviors: Newdirections for rational emotive behavior therapy. Buffalo, NY: PrometheusBooks.

Ellis, A., & Dryden, W. (1990). The basic practice of RET. In W. Dryden (Ed.),The essential Albert Ellis (pp. 3–30). New York: Springer.

Ellis Sichel, A. J., Yeager, R., DiMattia, D., & DiGiuseppe, R. (1989). Rational- emotive couples therapy. New York: Pergamon.Ellis, A., & Yeager, R. J. (1989). Why some therapies don’t work: the dangers of

transpersonal psychology. Buffalo, NY: Prometheus Books.Erickson M. H. (1980). Further clinical techniques of hypnosis: Utilization

techniques. In Rossi E. L. (Ed.), The collected papers of Milton H. Erickson.(Vol. 1, pp. 177–205). New York: Irvington.

Held, B. S. (1986). The relationship between individual psychologies andstrategic/systemic therapies reconsidered. In D. E. Efron (Ed.), Journeys:

Expansion of the strategic-systemic therapies (pp. 222–260). New York:

Brunner/Mazel.Held, B. S. (1992). The problem of strategy within the systemic therapies.

Journal of Marital and Family Therapy, 18, 25–35.Liddle, H. A. (1982). On the problem of eclecticism: A call for epistemological

clarification and human-scale theories. Family Process, 21, 243–250.



22/22

Meichenbaum, D. (1977). Cognitive-behavior modification: An integrativeapproach. New York: Plenum.

Molnar, A., & de Shazer, S. (1987). Solution-focused therapy: Toward theidentification of therapeutic tasks. Journal of Marital and FamilyTherapy, 13, 349–358.

Norcross, J. C. (1990). Commentary: Eclecticism misrepresented and integra-tion misunderstood. Psychotherapy, 27 , 297–300.

Norcross, J. C., & Goldfried, M. (1992). Handbook of psychotherapy integra-tion. New York: Basic Books.

O’Hanlon, W. H., & Weiner-Davis, M. (1989). In search of solutions: A newdirection in psychotherapy. New York: Norton.

Paul, G. L. (1967). Strategy of outcome research in psychotherapy. Journal of Consulting Psychology, 31, 109–119.

Petzold, C. (1981). Erickson and Ellis: An elegant integration based on theinnovative techniques of both. Corrective and Social Psychiatry and

Journal of Behavior Technology Methods and Therapy, 27 (1), 27–34.Safran, J. D., & Messer, S. B. (1997). Psychotherapy integration: A postmod-

ern critique. Clinical Psychology: Science and Practice, 4, 140–152.Walen, S. R., DiGiuseppe, R., & Dryden, W. (1992). A practitioner’s guide to

rational-emotive therapy. New York: Oxford University Press.


A Solution-focused Approach to Rational-emotive Behavior Therapy - Toward a Theoretical Integration

Documents

Transcript of A Solution-focused Approach to Rational-emotive Behavior Therapy - Toward a Theoretical Integration