You are on page 1of 4

Applying an Integrated Approach 1

outstandingly well, they must be treated fairly by all people,


and that conditions must be favorable at all times in their life
Applying an Integrated Approach to a Case Example: or else their life is horrible.
Cognitive Behavioral Therapy and Person Centered Therapy The goal of CBT is to identify and change those
Kelli Rodriguez irrational beliefs or maladaptive thoughts that are contributing
Capella University to the client’s problems. The function of the therapist is to
teach the client how to identify irrational and self-defeating
tendencies and then to challenge them, and replace them with
more rational and self-helping ones. “CBT is a structured
Applying an Intergraded Approach to a Case Example: form of therapy that moves through phases and where the
Cognitive Behavioral Therapy and Person Centered Therapy therapist has a relatively high activity level, in that the
therapist may direct and focus treatment” (Josefowitz &
Theory plays an important role in the process and Myran, 2005, p. 330). Throughout the helping process, the
outcome of therapy. For this reason, it is a topic that is client is expected to play an active and collaborative role
examined in depth in human service education programs and where they are held responsible for making changes happen.
research. Theory is used to explain client problems and to CBT is an action-directive, solution-focused approach to
dictate what is done in the counseling process (Hackney, 1992). therapy. The basic process of CBT used to help clients
Theory can be used to define “the nature of the relationship eradicate irrational briefs and move towards their goals in
between the counselor and client, to conceptualize the nature of more effective and efficient manner is as follows:
the presenting problem(s), and to define the resulting counseling 1. problem definition and goal setting
goals or desired outcomes” (p.2). 2. accessing and examining thoughts, identifying
In the past, much focus has been paid on delineating irrational beliefs
and accentuating the differences between the many theories of 3. disputing irrational beliefs and other cognitive-
therapy (Sprenkle, 2003, p. 93). Today, there is a move towards behavioral techniques
convergence of theories within the helping practices (Hackney, 4. assigning homework and tasks
1992, p. 3; Sprenkle, 2003). Researchers and practitioners are 5. re-evaluating the problem and goal (Guterman, 2005,
searching for an integrated approach which emphasizes the key pp. 230-239).
components within the helping process and relationship that
have been linked to effective therapy (Hackney, 1992, p.2). In the problem definition and goal setting stage of
Cognitive-behavioral therapy (CBT) and Person- therapy, the client is asked to explain what problem brings
Centered Therapy (PCT) have been shown to bring about them to therapy and what they would like to accomplish
positive changes in therapy. CBT and PCT, like all single-theory through therapy. The second step involves exploring the
approaches, have limitations. Literature suggests that when the client’s world through probing and listening. As the client
change-producing techniques of CBT and PCT are combined describes the problem and their situation, the therapist is
and applied, counseling is more effective (Josefowitz & Myran, accessing and examining the client’s thoughts to identify any
2005; Tursi & Cochran, 2006). In this paper, CBT and PCT are irrational beliefs or maladaptive behaviors. During this step,
reviewed and then integrated into one approach. A case example the therapist will educate the client on Ellis’s ABC theory and
is then presented and hypothetical helping sessions are described encourage the client to conceptualize his or her problem and
to demonstrate how the various techniques of the approaches can situation in terms of the ABC theory. The therapist also
come together to create positive changes in therapy. A introduces the three core irrational beliefs and helps the client
discussion follows that suggests future research and identifies understand the role they play in the client’s problem. The next
additional resources. step involves disputing the identified irrational beliefs. A
CBT variety of cognitive, emotive, and behavioral techniques are
Cognitive behavioral therapy (CBT) refers to a group of used in CBT “to help individuals dispute irrational beliefs,
approaches (i.e. rational emotive therapy, cognitive therapy) that and, in turn, eradicate emotional and behavioral problems so
assume a client’s cognitions shape the way they act and feel. that they can work towards their goals in an effective and
CBT approaches focus on how irrational beliefs or maladaptive efficient manner” (Guterman & Rudes, 2005, p. 226). Such
thoughts contribute to the client’s maladaptive emotions and techniques include teaching the client to be able to identifying
behaviors. Robert Ellis’s ABC theory is often used in CBT self-defeating thoughts, feelings, and behaviors; exposing the
literature to explain “the process whereby humans become client to ways to challenge an dispute irrational beliefs;
emotionally and behaviorally disturbed” (Guterman & Rudes, fostering the restructuring of cognitive distortions; teaching
2005). The theory asserts that dysfunctional cognitions about and promoting rational self-talk; reframing (situations are
events in one’s lives, not the undesirable events themselves, are viewed in a more favorable way); problem-solving; role-
what bring about maladaptive behavior and emotions in clients. playing; modeling; implosion, vivo desensitization,
David, Szentagotai, Eva, & Macavei (2005) explains Ellis’s bibliotherapy (becoming educated about the problem); and
ABC model as follows: “…people experience undesirable teaching clients how to change their own thinking and
activating events (A) about which they have rational and effectively managing their reactions to stressful people and
irrational beliefs (B). These beliefs lead to emotional, situations (Gutterman & Rudes, 2005, pp. 232-233). The final
behavioral, and cognitive consequences (C). Rational beliefs steps of CBT involve the therapist assigning homework
lead to functional consequences, while irrational beliefs lead to exercises and reevaluating the problem and goal (Ellis, 2003;
dysfunctional consequences” (p. 176). Hackney, 1992).
According to Guterman and Rudes (2005), “Irrational Although, numerous studies (David et al, 2005;
beliefs…tend to be absolute, dogmatic, and demanding and take Josefowitz & Myran, 2005) have shown CBT to be successful
the form of musts, shoulds, and oughts… When humans hold at improving the well-being of clients experiencing a wide
irrational beliefs about negative events in their lives, these range of difficulties, CBT has not reached “the desired
generally correspond to self-defeating….emotions and behaviors standard” of efficacy and effectiveness (David et al, 2005,
(e.g. depression, anxiety, addiction) that usually block one from 329). According to David et al, 30-40% of people are non-
working toward their goals….” (p. 225-226). Ellis (2003) responsive to CBT interventions. A major limitation of CBT,
attributes people’s maladaptive behavior to three core irrational according to Josefowitz and Myran (2005), is that although
beliefs, which include the belief that they must achieve CBT realizes the importance of a collaborative relationship, it
Applying an Integrated Approach 2
fails to place an emphasis on identifying and integrating specific the therapist understands what the client is saying, is
techniques into the helping process that are known to foster a genuinely interested, is empathetic, and is accepting.
collaborative, therapeutic relationship. Reflecting leads to the clarification step. When the therapist
PCT reflects the message back to the client, the client is given an
Person-centered approach (PCT), on the other hand, opportunity to correct the therapist if the therapist doesn’t
places a strong emphasis on the therapeutic relationship. PCT fully understand what the client was saying and also provides
evolved out of the extensive therapy field work and research of an opportunity for the client to further elaborate on and
Carl Rogers. According to Kirschenbaum (2004), Rogers explore their problem and situation. Throughout PCT,
believed the following: questioning, interpretation, suggestions, advice, and other
“that the client has within himself the directive techniques are avoided. Instead, PCT involves,
capacity, latent if not evident, to “carefully listening to the client, accepting the client for who
understand those aspects of his life and he or she is-no matter how confused or antisocial that might be
of himself which are causing him pain, at the moment-and skillfully reflecting back the client’s
and the capacity and the tendency to feelings. The acceptance and reflection of feelings would
reorganize himself and his relationship create a level of safety for deeper exploration and a mirror in
to life in the direction of self- which to further understand and reflect on the client’s own
actualization and maturity in such a way experience, which would lead the individual to further insight
as to bring a greater degree of internal and positive action” (Kirschenbaum, 2004, p. 118). In PCT,
comfort” (p. 118). the therapist strives to create a strong therapeutic relationship
by demonstrating genuineness, acceptance, and empathy.
According to PCT, clients experience dysfunction when When these conditions exist, the client is encouraged to
there is not congruence between the way they see themselves explore their situation, discover what concerns them, and
(self-concept), the way they would like to be (ideal self), and the identify ways they can make positive changes in their lives.
way they actually are (real self). A client may have experienced Tursi and Cochran (2006) supports the effectives of
a decrease in self-acceptance as a result of being judged in the PCT. Numerous studies have shown the importance of a
past. The resulting lack of congruence can interfere with the strong therapeutic relationship (Ellis, 2003; Motschnig &
client’s natural capacity to self-actualize. Nykl, 2003; Tursi & Cochran, 2006). Still though, PCT has
The premise of PCT is that every client has the limitations. A major limitation of PCT, according to
resources for personal development and growth and the goal of Motschnig and Nykl (2003), is that it can lack structure and
PCT is to “tap into, strengthen, or restart this naturally occurring use of action-oriented intervention techniques
positive growth potential” (Tursi & Cochran, 2006, p. 388). Integration of BCT and PCT
Rogers believed that what “clients need is not the judgment, Although CBT and PCT have been found to bring
interpretation, advice or direction of experts, but supportive about positive changes in therapy, they each have their
counselors and therapists to help them rediscover and trust their limitations. According to Tursi and Cochran (2006), “It is
‘inner experiencing’…, achieve their own insights, and set their difficult to find one counseling approach that will
own direction” (Kirschenbaum, 2004, p. 121). The function of satisfactorily lead to positive personality change for every
the therapist in PCT is to provide favorable conditions for the client with every counselor” (p. 387). There is a movement
natural phenomenon of person growth to occur. According to towards integration of therapy models as the helping field
Rogers (1957), a therapist must be empathetic, communicate an seems to be realizing the limitations of adopting a single
unconditional positive regard for the client, and shows approach (Guterman & Rudes, 2005). According to Guterman
genuineness or congruence. These three core conditions foster a and Rudes (2005), “theoretical integration refers to combining
strong therapeutic relationship and create a psychological two or more distinct theories and thereby producing a new,
atmosphere where the client does not feel judged, where they super ordinate clinical framework” (p. 224). Guterman and
can feel safe to examine their situations, and where they can be Rudes (2005) go on to suggest that integrating CBT and PCT
empowered to take the steps necessary to grow and self- “addresses the limitations of each model while enhancing their
actualize. In PCT, the client is viewed as the change-maker, they respective strengths” (p. 241). The strength of CBT is its
are held responsible for making changes occur, and all work emphasis on process and action (i.e. goal setting, collaborative
done by the therapist is aimed at fostering the natural self- action, etc.), but it has been criticized as lacking an emphasis
actualizing capabilities within the client. on the factors that develop a strong therapeutic relationship.
PCT is a non-directive approach to therapy. The basic The strength of PCT is its emphasis on the relationship
process of PCT used to empower the client to help themselves (creating a strong working alliance), but it has been criticized
and to foster client self-actualization is as follows: as lacking in structure. By combining CBT and PCT, a “super
1. expressing of feelings ordinate clinical framework” is created that emphasizes both a
2. reflecting of client’s problem and situation positive relationship (PCT) and provides structure and
3. clarification of client’s problem and situation interventions (CBT) (Guterman & Rudes, 2005, p. 224).
According to Tursi and Cochran (2006) CBT and
4. client decides what changes to make to achieve PCT are compatible and can work well together (p. 387). The
personal growth (Josefowitz & Myran, 2005, pp. 331- integrated approach pulls from the change-producing
334). techniques of CBT and PCT. PCT contributes its emphasis on
demonstrating the three core conditions necessary for a strong
In the expression of feelings step, the client is therapeutic alliance. CBT offers its emphasis on structure and
encouraged to discuss what they feel is troubling them. As the provides a wide array of cognitive and behavioral
client discusses his or her situation, problem, and feelings, the interventions. The process of the integrated model takes on a
therapist is listening carefully and showing an acceptance of the similar structure as the CBT process discussed above, but adds
client through nonverbal and verbal techniques (i.e. nodding an emphasis on developing and strengthening the therapeutic
head, looking at the client while they are talking, smiling, saying alliance throughout each step.
‘umm’). The next step is reflection. The therapist extracts the 1. problem definition, goal setting, agenda
core message and feelings of what the client has said and 2. self-exploration, assessing and examining
communicates it back to the client. Skillful reflecting or thought, identifying irrational beliefs
mirroring of the message back to the client, demonstrates that
Applying an Integrated Approach 3
3. disputing irrational beliefs, cognitive restructuring provided education on Ellis’ ABC theory and encouraged Dale
and other cognitive-behavioral intervention to conceptualize how his guilt over being depressed was
4. assigning homework and tasks causing him additional distress. Dale’s belief that he must not
5. re-evaluate the problem and goals (Guterman & be depressed or he is inadequate husband was identified as an
Rudes, pp. 230-239; Josefowitz & Myran, 2005, irrational belief and was challenged. Dale realized that it was
pp. 331-334; Tursi & Cochran, 2006, pp. 388-393). rational to be concerned about his depression as that concern
brought him to therapy, but feeling guilty about being
The first step is goal-setting and articulating an agenda. depression was irrational and not helping his situation. Dale
This is a collaborative process, where the “therapist encourages was asked to read a pamphlet on rational emotive and
client to become more specific through reflection and questions” behavioral therapy. He was asked to think about personal
(Josefowitz & Myran, 2005, p. 331). The demonstration of the example of each of Ellis’s 3 core irrational beliefs that were
core conditions of PCT is important in this step, as well as discussed in the session. The therapist thought this exercise
throughout the entire helping process. Empathy and congruence would help Dale begin to identify and dispute the irrational
(genuine curiosity) are necessary if a counselor is to accurately beliefs that are contributing to his depression. At the end of
reflect and question in a way that encourages client self- the session, Dale was encouraged to re-evaluate the problem
exploration/understanding. Positive regard is needed for the and goals for therapy. Dale expressed his desire to learn more
client to feel comfortable enough for self-exploration about how his thinking influences his depressive state. He
(Josefowitz & Myran, 2005). The next step involves identifying explained that the session had got him thinking about ways he
and examining the thought most central to the client’s distress. can change his mental state, rather than just focusing on how
This step also requires an empathetic, non-judgmental, genuine his depression is debilitating him.
therapeutic relationship, where the client is encouraged to
explore his thoughts and the meaning he brings to the situation Session 2
(pp. 333-334). This will include the counselor educating the At the beginning of the session, Dale gave an update
client on Ellis’s ABC model and the three core irrational beliefs. on how he was feeling and talked about what he would like to
The therapist will encourage the client to examine how his accomplish in the session. Dale explained that he was still
problem is caused by irrational beliefs. Next, alternate thoughts feeling ‘bummed’ and was craving to feel ‘alive’ again. With
are created. Balanced thought or a new thought are developed this said, the goal of the session became using self-exploration
by the client though the exploration process. Other CB to identify ways he can positively influence his mood. Dale
techniques are introduced at this point to dispute irrational was asked to talk about what he used to do for fun. In this
beliefs and to replace them with rational thought. Homework discussion, another irrational belief was identified. Over the
assignments and tasks are assigned that strengthen the skills years, Dale has stopped playing cards with his friends because
introduced in the session. Lastly, the problem and goals are his wife did not think he should engage in social activities
reevaluated and changes to the agenda are made, if needed. without her. The therapist encouraged self-exploration around
Case Example this problem. The problem was conceptualized in terms of the
The case example is presented next and is used to ABC theory, where his wife’s discontentment with him
demonstrate how an integrative model of CBT and PCT can be playing cards is the activating event (A). The belief (B),
effectively applied in therapy. which leads to the consequence, is that, because he is married,
Dale is a 51 year old married man who presented with the he should only engage in activities with his wife. The
problem of depression. In the intake interview, Dale stated that consequence (C) is feeling deprived and resentful. The
he has been diagnosed with depression over two years ago and therapist did not dispute this belief, but allowed Dale to
had experienced little relief after trying different types of explore how he can change his belief (B) and as a result, the
depression medication. consequence (C) with regard to this problem and other marital
disagreements. Dale came to the conclusion that he and his
Session 1 wife needed to discuss their difference in view on how to
The first session started with the therapist (T) asking Dale spend their recreational time. The therapist assigned an
(D) what problem brought him to therapy and also what he exercise, “Negotiating socializing preference difference” from
would like to accomplish from therapy. The following is an Schultheis, O’Hanlon, and O’Hanlon’s (1999) Brief Couples
excerpt of the dialog on this: Therapy Homework Planner. The goal of the exercise is to
D: I don’t do any of the things I used to enjoy. I don’t feel “help the couple get a clear idea of their socializing
like I have the energy or desire to be involved or be around other preferences [and]…help the couple find and plan mutually
people. I just want to feel like my old self again. agreeable social arrangements” (p. 114). At the end of the
T: You feel that something has changed in your life and not session, the problem of depression and the goal of helping
in a good way. identifying activities he enjoys was reevaluated. During the
D: Yes. I used to be that guy that was the life of the party. I self-exploration of the session, activities, such as playing cards
used to be such fun. I used to make my wife laugh so hard. We and bowling, were identified as activities he enjoys. Irrational
used to get along so well and have such a good time with each beliefs that were preventing Dale from engaging in preferred
other. activities were identified and challenged. Dale realized that
T: You notice that this change is negatively affecting your part of the problem was that he was feeling deprived of
marriage as well. recreational activities he enjoys and resentful towards his wife
D: I feel guilty that my wife has to deal with my bad for prohibiting him from being involved. With this realization,
moods. It’s not fair to her. She deserves so much better and I Dale made it his goal to discuss and come to some agreement
just don’t know how to change how I am feeling. with his wife on recreational activities and to plan a preferred
activity during the week.
At the beginning of the session, Dale identified the problem
as depression and the identified the goal as wanting to feel like The following eight sessions that followed played out in a
his old self again The therapist encouraged Dale to explore his similar manner. Each session started with problem definition,
situation and problem. The therapist communicated empathy, a goal-setting, and the creation of an agenda. Throughout each
genuine interest, and acceptance throughout the session by using session, there was a strong emphasis on creating rapport and a
nonverbal cues (facial expressions, nodding, etc.) and effectively trusting environment for self-exploration. Acceptance,
reflecting Dale’s message. During the session, the therapist empathy, and genuineness were conveyed through non-verbal
Applying an Integrated Approach 4
communication (eye contact, nodding of head, smiling) and identifying the irrational beliefs, and an exercise to be
through verbal reflection of the client’s message. The therapists worked on with his wife pertaining to recreational
encouraged Dale to assess and examine his thoughts and to activities.
conceptualize his problem in terms of the ABC theory. Further 8. The problem and goals were reevaluated in light of
self-exploration was encouraged and various cognitive and the new insight gained and skills learned in the
behavioral interventions were used to identify and dispute session and through assignments.
irrational beliefs (I.e. reframing, positive self-talk, psycho By the end of the therapy, the client’s natural
education, problem-solving, etc) (Guterman & rudes, 2005, p. capabilities to grow and self-actualize were revitalized.
232). At the end of the session, homework assignments and tasks The case study demonstrated how the use of an integrated
were assigned to help Dale practice what was learned in the CBT and PCT can be used to bring about positive changes
therapy session, including numerous ones from Schultheis at al in therapy. Tursi and Cochran (2006) warn though that
(1999). The problem and goals were reevaluated in light of the effectively applying an integrated approach is not an easy
insight and understanding that was gained in each session. task, “It requires multiple areas of expertise from
After the tenth sessions, Dale informed the therapist counselors, when even just one can take years to
that he was feeling like his old self again. He was enjoying accomplish” (p. 394). Motschnig and Nykl (2003)
being involved in a weekly card night and in other recreational suggest another limitation of integrated models, such as
activities he found interesting. He reported that he and his wife that used in the case example, is that “the model…is
have been able to communicate their needs and wants better and abstract in its initial version and intended to be refined”
they have joined a bowling league together. He is now more (p. 36). Further research is needed to answer the “many
aware of his irrational beliefs and how they influence his questions that remain regarding the theory, research, and
feelings and behaviors. He feels empowered to make positive practice of this integrative model” (Guterman, 2005, p.
changes in his life. He realizes the way he views a situation can 240). This research should include both qualitative and
be changed through self-exploration or by using a variety of quantitative studies that evaluate the effectiveness of
cognitive or behavioral strategies that were introduced and various integrative approaches. Additional literature is
practiced in therapy and homework assignments. needed that presents case examples and demonstrates how
Discussion the techniques of integrative approaches, such as the one
This paper examined two popular approaches to therapy, examined in this paper, can be applied to address specific
CBT and PCT. Although both approaches have been shown to client problems in therapy.
be effective forms of therapy, they still have limitations. In conclusion, the movement towards integration of
Literature suggested that no one approach can address all approaches “may be worthwhile endeavors so long as
problems with all clients. This realization has created a therapists recognize the importance of developing
movement towards theoretical integration. Literature suggests integrative models that are systematic and consistent”
that the integration of CBT and PCT could result in a more (Guterman, 2005, p. 242).
comprehensive and effective approach to therapy. In the case
example, an integrated approach to therapy was used.
Techniques from CBT and PCT were used to address the client’s
problem with depression. Much was accomplished throughout
the helping process. The major steps and accomplishments of
the integrated approach used in the case example, includes the
following:
1. Genuineness, empathy, and acceptance were conveyed
by the therapist. By these three conditions being
present, an atmosphere was created where positive
changes could take place.
2. A safe, trusting therapeutic atmosphere encouraged
self-exploration.
3. Exploration of the client’s situation and problem was
encouraged.
4. Psycho education on Elli’s ABC theory and the core
irrational beliefs was conducted. The client’s problem
was explained in terms of the theory, where A is the
activating event, B is the belief about the activating
event, and C is the consequence. By conceptualizing
the problem in such a way, the client realized they he
has the power to change the consequences (C) by
changing the belief (B) he hold about the activating
event.
5. Through client self-exploration and effective reflection
on the part of the therapist, irrational beliefs were
identified. The skill of identifying irrational beliefs
within the client’s situation and problem was practiced
throughout the sessions and assigned tasks.
6. Cognitive restructuring was encouraged through self-
exploration and through an introduction of various
cognitive and behavioral interventions. Including
reframing, rational self-talk, problem-solving, and
psycho education.
7. Homework assignments and tasks assigned to reinforce
lessons and skills learned in session. These included
assignments to read about Ellis’s ABC theory, practice