Cognitive Behavioral Approaches for Counselors


Diane Shea

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    Series Preface

    “Theories for Counselors” provides practical applications of major theories from a common factors, multicultural perspective. What does that mean? Let’s break it down.

    The authors in the “Theories for Counselors” series are highly experienced counselors with extensive knowledge and expertise concerning the theory that they present. They present each theory from an applied perspective, asking themselves, “How is this concept useful in actual clinical practice?” It may surprise you to know this, but Freud’s work can be (and is) applied day in and day out in modern counseling. (If this surprises you, it could indicate that you have not been taught Freud well.) He believed that the relationship between the client and clinician was of utmost importance; he believed that his patients needed to feel comfortable speaking their mind; he believed that clinicians needed to listen with attentiveness and tact. Freud’s legacy, as is shown in the first book of this series, Psychoanalytic Approaches for Counselors, has been revised and revisited, but its therapeutic usefulness remains, and for each theory that is presented, therapeutic utility is utmost on the minds of the authors as they present material to their readers.

    Each book begins by addressing the two most vital themes common to any counseling theory: the client and the therapeutic relationship. Why have we picked the client and the therapeutic relationship as the two most important themes? The reason is called the common factors hypothesis, and this is where research comes in. The common factor hypothesis is the result of decades of research that has compared various schools of counseling and psychotherapy. Contrary to prior belief, it has been convincingly demonstrated that research in general finds no significant difference in how effective the various therapies are. These findings, predicted by Rosenzweig (1936/2002) nearly 80 years ago, began to be empirically demonstrated in the mid-1970s (Luborsky, Singer, & Luborsky, 1975; Smith & Glass, 1977). Research confirming the relative equivalence of bona fide therapies has accumulated since that time (e.g., Ahn & Wampold, 2001; Lambert, 1992; Lambert & Barley, 2001; Lambert & Ogles, 2004; Wampold, Mondin, Moody, Stich, Benson, & Ahn, 1997).

    What does this mean? It means that instead of therapeutic improvement being due to specific ingredients prescribed by different theoretical schools of counseling and psychotherapy, positive therapeutic change can be attributed to factors that are common to all bona fide therapies. Additionally, these factors can be broken down into four categories: client variables (40% of change), relationship variables (30%), hope and expectancy (15%), and theory or technique (15%) (Duncan, 2002b; Lambert, 1992) (see Figure 1).

    Figure 1 Common Factors

    Source: Lambert, M. J. (1992). Psychotherapy outcome research: Implications for integrative and eclectic therapists. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy and behavior change (4th ed., pp. 143–189). New York, NY: John Wiley.

    As we see, the client and the relationship account for the vast majority of therapeutic change, and as such, should be centrally located in the presentation of any counseling theory.

    Interestingly, the history of counseling begins right where research predicts: in an intense relationship between one person who wants help and another person wanting to help. Sigmund Freud, who inaugurated themes that continue to organize the counseling profession, described and redescribed the origins of psychoanalysis. Two major components in his descriptions were the famous first patient of psychoanalysis, Bertha Pappenheim (referred to in case studies as “Anna O.”), and the relationship she had with her doctor, Josef Breuer, Freud’s friend and colleague at the time. Though Freud revised his opinions on many things about that famous case (as he did about almost everything), what remained constant was the fact that he saw something of primary importance in that case—the “talking cure” that occurs between a patient/client and doctor/counselor.

    Thus the origins of counseling display a deep consonance with the latest in empirical research, and it is this consonance that is the underlying theme behind the series “Theories for Counselors.” Starting with Freud and moving through past and contemporary counseling theories and theorists, the focus remains on the client and the therapeutic relationship, and how this relationship fosters and enhances the client’s natural resilience and hope for change. The theory’s techniques and the theory itself are important only inasmuch as they provide a common roadmap—a way for both client and counselor to think about where a client has been and where he or she wants to go.

    Just as it is important to know that Freud remains useful for contemporary counselors, so it is important to know that Freud began his work against a backdrop of rising racial hatred in Austria and Western Europe, and that while he successfully fled to England in 1938, his sisters perished in the Nazi concentration camps during the Holocaust (Gay, 2006). Thus the counseling enterprise began at a time of extreme racial hatred, which is a sobering and important fact to reflect on; from the inception of counseling in Western Europe and throughout its development worldwide, multicultural awareness and respect for diversity are no mere add-ons but are integral components for the practice of counseling. In addition, another important group membership—gender—has assumed greater and greater importance in the counseling field; its central importance imbued the case of Bertha Pappenheim, which has been deemed the founding one for psychoanalysis and hence for all that followed.

    Counselors must practice from a culturally aware place rather than one that would seek to downplay the impact of race, gender, and other important group affiliations on our clients’ lives. Sue, Arredondo, and McDavis (1992) provided a conceptual framework for organizing the types of competencies needed by a culturally skilled counselor, saying that he or she becomes aware of his or her own assumptions, actively attempts to understand differing worldviews, and actively develops culturally sensitive intervention strategies and skills. Sue (2001) expanded his conceptual framework into a multidimensional model of cultural competence; this model was primarily focused on racial and ethnic minority groups, though he did also recognize that it might be applicable for other groups including those of “gender, sexual orientation, and ability/disability” (p. 816). Such topics are now recognized as rightfully fitting within the context of multicultural counseling (Conyers, 2002; Pope, 2002; Richardson & Jacob, 2002). In addition, Smith and Richards (2002) point out the obligation that counselors have to address issues of religion and spirituality as multicultural issues.

    D’Andrea and Daniels (2001) provided a multicultural framework for working with clients that is RESPECTFUL and inclusive of Religion and spirituality, Economic class, Sexual identity, Psychological development, Ethnic/racial identity, Chronology, Trauma, Family, Unique physical abilities and disabilities, and Language and location of residence. Similarly, Hays (1996) outlined a model that emphasized nine cultural influences in relation to specific minority groups that counselors should be ADDRESSING: Age, Developmental and other Disabilities, Religion, Ethnicity/race, Social status, Sexual orientation, Indigenous heritage, and Gender. These models help counselors deliver diversity competent services and pay attention to all the potential resources that a client brings to the counseling encounter. Ultimately, respect for diversity and celebration of all aspects of culture and group membership should lead to a more nuanced understanding of the client and the sometimes-hidden strengths that he or she possesses. Better knowing a client enhances the richly relational counseling encounter that began with Freud’s work.

    Once again, this is consonant with the common factors approach. The common factors approach can be applied to, and makes sense of, any counseling theory, beginning with Freud and psychoanalysis. According to this approach, all bona fide counseling theories do the same thing, though they describe it using differing terminology. One analogy is traveling to a particular destination, say New York City. There is no one right way to get there—it depends on where you are starting from, whether you want to fly, drive, or take the train, and whether you want to get there by a direct route or take a scenic one. Each unique route is analogous to a different counseling theory. The destination is the same—in a travel scenario, getting to New York City, and in a counseling scenario, achieving positive treatment outcome.

    In their book, The Heroic Client, Duncan and Miller (2000) put it this way—they seek to “(1) enhance those factors across theories that account for successful outcome; (2) encourage the client’s unique integration of different theories; and (3) selectively apply diverse ideas and techniques as they are seen as relevant by the client” (p. 146). Miller has talked about the need for clinicians to know different theories because they serve as language resources to connect with the client. In this view, theory is a way to connect with clients; if one language that I’m using—for instance, solution focus therapy—doesn’t appear to be the language that the client is speaking, then I should use other theoretical languages that might allow me to communicate better with my client. The test of the theory is in how well it accords with each individual client’s culturally influenced worldview and how useful it proves to be in the context of the therapeutic encounter.

    “Theories for Counselors” will help you consider theories from the perspective of the client and what makes sense to her or him. It will show that theory and technique are good inasmuch as they aid clients in understanding their present situation and what they need to do to improve it. Finally, the series will help you situate the work of counseling within a sociocultural framework that takes into account client uniqueness, universality, and important group affiliations to enhance and activate client resources.

    Finally, I direct the reader to the companion website for this book and series, There you will find extended discussions of topics that are mentioned briefly in the text, topics that are not addressed in the text but that might be useful to know when studying for comprehensive or licensing exams, definitions of terms, and supplemental exercises and activities. In general, if a topic is not covered or is covered in detail in the printed text, please search the website, as it will in all likelihood be discussed there.


    I first want to thank Fred Redekop for his invitation to be part of this endeavor. He encouraged and challenged me throughout the process of writing. Likewise, I am grateful for the help of my former student and research assistant, Barb Bisch. She is a counselor with great potential, and I look forward to seeing her make her own contributions to the field. I cannot forget the library staff at Holy Family. They were invaluable. In particular, Debby Kramer, who helped me track down hard-to-find original articles and books, while Chris Runowski and Kathy Kindness were always offering assistance and support. Finally, the folks at SAGE were wonderful to work with. Carrie Montoya, our editorial assistant, and Deanna Noga, copy editor, helped me with the final touches. An additional thanks to my friends and colleagues who gave me confidence that I could see this to completion!

    Publisher’s Acknowledgments

    SAGE gratefully acknowledges the contributions of the following reviewers:

    Carol Kottwitz DNP, ARNP

    Gonzaga University

    Kathleen R. Tusaie PhD, APRN-BC

    The University of Akron, College of Health Professions, School of Nursing

    Stephen Sidorsky, LCSW

    Adjunct Instructor

    Rutgers University School of Social Work


    My family, friends, and many, many coworkers and students have inspired me and encouraged me over the years. I dedicate this book to you who have taught me that relationship is the common factor in life that can promote compassion and community.


    Recently I had the opportunity to participate in the 46th Annual Convention of the Association for Behavioral and Cognitive Therapies (ABCT). In one of the panel discussions, experts from various approaches to cognitive and behavioral therapies acknowledged that overzealous alliance to specific treatment interventions might even inadvertently lead to adverse effects with certain clients. Since the panelists acknowledged that many of the interventions were found to be equally effective, their discussion focused on searching for common ground. One panelist remarked that the interpersonal alliance is crucial. I agree. My suggestion is that the most essential common ground in all cognitive and behavioral approaches is the counselor’s relationship with the client.

    In this book, I introduce prospective counselors to Rational Emotive Behavior Therapy (REBT) as developed by Albert Ellis in the mid-1950s and Cognitive Behavioral Therapy (CBT) as developed by Aaron Beck in the early 1960s. I emphasize that the focus of REBT/CBT has always been on the client and the quality of the counseling relationship. These are paramount, even though some critics of REBT/CBT have suggested that the therapeutic relationship has often been overlooked or underemphasized. In contrast, I argue that, in fact, Ellis and Beck have added unique perspectives to our understanding of the therapeutic relationship. I begin by presenting a brief historical background sketch for REBT and CBT.

    Albert Ellis and REBT

    Son of Jewish parents, founder of REBT, Albert Ellis was born in Pittsburgh, Pennsylvania, on September 27, 1913. In his autobiography, Ellis (2010) described his mother as an incessant talker and his father as a successful salesman. He had two younger siblings, a brother 19 months younger and a sister born when he was 4 years old. At age 4 the family moved to New York City, where he was raised. Ellis first received a Bachelor of Business Administration in 1934 from New York’s City College. He then studied clinical psychology in New York’s Columbia University, where he received his MA in 1943 and his PhD in 1947.

    Initially, Ellis was trained to counsel persons with family, marital, and sexual issues. Not satisfied with this, he began intensive training in psychoanalysis. Although he admitted early on that he had serious reservations about Freud’s theory of personality, he continued to practice classical psychoanalysis. But, in his own words, while he enjoyed picking the brains of his patients to uncover hidden meanings in their dreams, he mused, “I soon found, alas, that I had to honestly admit to myself (and sometimes the patient as well) that I was usually dead wrong about this” (Ellis, 1962, p. 6). This caused Ellis to modify his approach to psychoanalysis. He became much more eclectic and actively engaged with his clients. However, he continued to become frustrated with patients who refused to take steps to alleviate their fears. He then turned to more behaviorist notions.

    Exploring the notions of deconditioning as espoused by such psychotherapists as Wolpe and Salter, Ellis began to incorporate risk-taking activities with his patients, encouraging them to do the things they may actually fear. However, when a patient suggested that she or he may have been conditioned in early childhood to fear rejection by her or his parents, the patient might not actually overcome the fear. In other words, a patient’s insight into his or her behavior didn’t necessarily bring about change. This led Ellis to explore the question of why patients held on to illogical fears. He developed the idea that language and self-talk contributed to the development and maintenance of neurosis. By this time, Ellis considered himself a rational therapist and incorporated his insights into his private practice and delivered his first of a series of papers on rational therapy to the psychological community in 1955.

    In 1959, Ellis founded his own institute, the renowned not-for-profit Institute for Rational-Emotive Therapy. By 1964, the Institute had grown and Ellis purchased a building in Manhattan, New York, which is today the Albert Ellis Institute.

    Over the years, Ellis was a prolific writer and lecturer and sought after psychotherapist. He served as the president of the American Psychological Society’s (APA) Division of Consulting Psychology as well as the Society for the Scientific Study of Sexuality. He also served on the board of many professional societies. Over his lifetime, Ellis published over 800 scientific papers and edited or authored over 75 books and 200 audio and video cassettes. He received numerous distinguished awards as a prominent psychologist, and in 1971, he was honored by the American Humanist Association as the Humanist of the Year. Ellis died at home on July 24, 2007.

    Aaron Beck and CBT

    Nearly 9 years Ellis’s junior, Aaron Beck was born in Providence, Rhode Island, on July 18, 1921. He graduated from Brown University in 1942 and went on to study at Yale, where he earned his medical degree. Like Ellis, Beck was trained in psychoanalysis. He was a graduate of the Philadelphia Psychoanalytic Institute. From 1950 to 1952, he worked at the Austen Riggs Psychoanalytic Institute and spent much of his early career practicing classical psychoanalysis. As Beck recalled, by 1956, he ventured out to scientifically validate some of the psychoanalytic concepts of depression (Beck, Rush, Shaw, & Emery, 1979). This led to the development of what is known today as cognitive behavioral therapy (CBT).

    By 1994, Aaron Beck and his daughter Judith Beck founded the Beck Institute for Cognitive Behavior Therapy as a nonprofit 501(c)(3) in Bala Cynwyd, Pennsylvania. The institute has become an international training center providing CBT workshops and consultation worldwide.

    Like Ellis, Beck is a prolific writer. His publications include some 600 scholarly articles and 25 books. In addition, he has developed widely used assessment scales. Beck has also received numerous awards, including the Lasker-DeBakey Clinical Medical Research Award for his creation of cognitive therapy. He is an Honorary President of the Academy of Cognitive Therapy and a fellow of the American Academy of Arts and Sciences. Presently, Beck serves as President Emeritus of the Beck Institute.

    New Perspectives on the Therapeutic Relationship

    But why focus on the relationship? Is there evidence the therapeutic alliance or relationship is central to client improvement? Horvath and Symonds (1991) set out to examine this question. The results of their meta-analysis of 24 studies suggested that the quality of the therapeutic alliance as indicated by the clients’ ratings was the best predictor of successful treatment. Ten years later, in a much larger meta-analysis, these two authors along with two other colleagues concluded that independent of how the alliance was measured or what therapeutic approach was involved, “The quality of the alliance matters” (Horvath, Del Re, Flückiger, & Symonds, 2011, p. 13).

    Wampold (2010) further explained that from the common factors perspective, regardless of the specific theoretic approach to treatment, there are common factors that are “responsible for psychotherapeutic benefits rather than the ingredients to the particular theories” (p. 23). In the 1970s, researchers (Garfield, 1973; Garfield & Bergin, 1971; Strupp, 1973b) had been examining outcomes in psychotherapy in attempts to uncover the basic ingredients or common factors. Over a number of years these factors have been elaborated. Presently, authors (e.g., Duncan, 2002b; Lambert, 1992; Lambert & Barley, 2001) have pointed out that specific treatment techniques accounted for only 15% of treatment success, whereas the therapeutic alliance account for twice this, or 30% of the success. Factors outside counseling, that is, client variables, account for 40% of client improvement, and the hope or expectancy to improve, sometimes referred to as the placebo effect, account for another 15%.

    While the common factors hypothesis has been gaining consensus in modern times, as Duncan (2002b) pointed out, these notions can be traced back to a classic article that was written in 1936 by Saul Rosenzweig. Rosenzweig (1936/2002) recognized that every theoretical approach to psychotherapy has merit. He metaphorically borrowed from a scene in Alice in Wonderland and declared, “At last the Dodo said, ‘Everybody has won, and all must have prizes’” (p. 412). Following this, it seems logical that a more efficacious approach to counseling and therapy would be to develop treatments that are grounded in these common factors (Grencavage & Norcross, 1990), and in a recent interview with Lynne Shallcross (2012), Brad Elford pointed out that counselors should be mindful of each of these common factors if they want to help clients succeed. I do the same throughout this book.

    But what prize is in store for REBT/CBT? I invite you, prospective counselors, to understand how the two giants of REBT/CBT, Ellis and Beck, both trained as psychoanalysts, added unique understandings to the meaning of self-acceptance and unconditional positive regard within the context of the therapeutic relationship in a different form of talk therapy.

    In the first chapter, “Client and Relationship in REBT/CBT,” I focus more specifically on the client-counselor relationship and how it has been assessed and defended despite criticisms that REBT/CBT counselors often may seem to deemphasize its importance. I look at specific client factors that may contribute to REBT/CBT’s success or failure. I also discuss some of the challenges inherently related to REBT/CBT when counselors are too wedded to the medical model and give themselves an aura of scientific authority. Ellis (1977a) poked fun at this when he said that “presumably intelligent men and women, with hell knows how many academic degrees behind them (which we may unhumorously refer to as degrees of restriction rather than degrees of freedom), consistently take themselves too seriously” (p. 60).

    In the second chapter, “Basic Tenets of REBT/CBT,” I provide a description of the basic tenets of REBT and CBT, suggesting similarities and differences. I rely on primary sources of Ellis and Beck as well as other experts in the field of CBT. I provide clinical vignettes and excerpts from verbatim counseling sessions that demonstrate how a client is led to challenge unhealthy beliefs that underlie disturbed emotions. This is often done through self-monitoring of negative thoughts and homework assignments. Two unique techniques that REBT often uses are rational-emotive imagery and shame-attacking exercises. I provide readers with examples and challenge them to practice a “shame-attack.”

    In the third chapter, “Evolution of REBT/CBT,” I focus on some “third-wave” therapies, which are considered under the umbrella of CBT. After World War II, there was a great need for more effective treatments for soldiers coming back from combat. This coincided with developments in the field of psychology where B. F. Skinner focused on the understanding of operant conditioning as a basis of behavior. Behaviorism developed as a “first wave” challenge to the traditional psychoanalytic therapy of Sigmund Freud. Later, in the 1960s, Ellis and Beck shifted attention to the role of cognitions in understanding human emotions and behavior. This was considered the “second wave” challenge to psychoanalysis. Now, 50 years later, there has been much growth and development in the field of REBT/CBT. The question has shifted to reexamining whether or not counselors should help clients control their thoughts or simply accept them. This has led to a “third wave” of cognitive therapies. Readers are introduced to (a) mindfulness-based cognitive therapy, (b) dialectical behavioral therapy, and (c) acceptance and commitment therapy. I cite research demonstrating the effectiveness of each of these and emphasize the importance of the therapeutic relationship for each. This chapter ends with a discussion of how neurobiological developments are impacting the understanding of many areas of mental health.

    In the fourth chapter, “Multiculturalism,” I describe how I believe a culturally competent, contemporary counselor, who is a proponent of REBT/ CBT, would integrate multicultural adaptations into his or her practice. I base this description on 10 steps outlined by Hays (2009):

    • Assessing the person’s and family’s needs with an emphasis on culturally respectful behavior.
    • Identifying culturally related strengths and supports.
    • Clarifying what part of the problem is primarily environmental (i.e., external to the client) and what part is cognitive (internal) with attention to cultural influences.
    • For environmentally based problems, focus on helping the client make changes that minimize stressors, increase personal strengths and supports, and build skills for interacting more effectively with the social and physical environment.
    • Validate clients’ self-reported experiences of oppression.
    • Emphasize collaboration over confrontation, with attention to client-counselor differences.
    • With cognitive restructuring, question the helpfulness (rather than the validity) of the thought or belief.
    • Do not challenge core cultural beliefs.
    • Use the client’s list of culturally related strengths and supports to develop a list of helpful cognitions to replace the unhelpful ones.
    • Develop weekly homework assignments with an emphasis on cultural congruence and client direction.

    In the fifth chapter, I begin with a case illustration that demonstrates how a counselor might approach a client using REBT/CBT but all the while being sensitive to developing a therapeutic alliance. I also show how REBT/CBT can be tailored for use with children and adolescents. Scripts are provided for a number of concrete exercises that are easily adapted and modified depending on the developmental level of the child.

    Finally, in the sixth chapter, I conclude with the reminder that the founders of REBT/CBT really did focus on the relationship they had with their clients. It was, in fact, by taking seriously their clients’ concerns about traditional psychoanalysis that REBT/CBT evolved. However, counselors who wish to practice REBT/CBT need not take on the persona of the founders. What they need to do is make sure they don’t neglect the therapeutic relationship; however, it may find final expression.

    Because humor in various forms has been interwoven into REBT/CBT, I end some chapters with one of Ellis’s Rationally Humorous songs. These songs show how humor can challenge unhelpful thoughts and patterns, in part by highlighting incongruities and contradictions expressed by clients.

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    About the Author

    Diane J. Shea, PhD, is an Associate Professor for the Graduate Program in Counseling Psychology at Holy Family University, Philadelphia, Pennsylvania. She is a Nationally Certified Psychologist, a PA Certified School Psychologist, and a Licensed Professional Counselor. In addition to her academic credentials, she is a broadly experienced human services provider. She was the founding director of Bethany House, a group home in New York for homeless teenage mothers and their babies. Her expertise also includes providing clinical services, managing clinical staff, and providing individual and family services for adolescents in the Juvenile Justice System.

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