Integrating Feminist Narrative Therapy, Person-Centered

Therapy, and Rational Emotive Behavioral Therapy:

A Short-Term Case Study

Loni Crumb

Abstract:

There is increased literature in the mental health field regarding the merits of
integrating techniques and procedures from multiple therapeutic frameworks to
facilitate a positive change process. This article presents an integrative approach
using feminist narrative therapy, person-centered therapy, and rational emotive
behavior therapy to address behavioral, emotional, and psychological concerns.
The author provides an overview of each therapeutic approach followed by a
justification of the theoretical and therapeutic viability. A case illustration is
provided to demonstrate the integration of the three noted therapeutic approaches.
Finally, limitations and implications for practice are discussed.

Keywords: Integrative, mental health, feminist narrative therapy, person-centered

therapy, rational emotive behavior therapy

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Introduction

Mental health professionals must be flexible in their therapeutic approaches

and interventions in order to accommodate the extensive psychological,
behavioral, social, and emotional concerns of diverse clientele (Erskine, 2015;

International Journal of Integrative Psychotherapy, Vol. 9, 2018 56

Erskine & Trautmann, 1996; Ratts & Greenleaf, 2018). Pairing evidenced-based
approaches, such as cognitive-behavioral therapies that consist of collaborative
therapeutic alliances and cognitive restructuring with culturally-responsive
approaches that support egalitarian relationships and social context exploration,
can help mental health professionals address the unique needs of diverse clients
and demonstrate measurable treatment outcomes (Crumb & Haskins, 2017;
Erskine, 2015). Nevertheless, there is a need for researchers and practitioners to
provide illustrations of how to practically integrate established therapeutic
approaches. In response to this need, the current article proposes the application
of feminist narrative therapy (FNT), person-centered therapy (PCT), and rational
emotive behavior therapy (REBT) through an integrative framework that comprises
elements from behavioral, humanistic, and postmodern paradigms. The integration
of such approaches may help mental health professionals to address a host of
personal and sociocultural matters that influence clients’ overall personal
development and well-being. The following sections provide an overview of the
theoretical composition and viability of FNT, PCT, and REBT, and a case
illustration demonstrating the use of the integrated approach. Finally, limitations
of the approach and implications for practice are provided.

Theoretical Composition

The integrative approach described in the current article was informed by

Prochaska’s (1995) transtheoretical therapy model which identified a series of
stages that people pass through when changing their behavior. The
transtheoretical model espouses that no one theory has the “monopoly of truth”
(Prochaska, 1995, p. 407). Prochaska postulated that practitioners could
systematically integrate insights and techniques from diverse therapies to meet the
need of the client. The maximum impact strategy of integration was utilized to
promote client growth that would influence change processes across the
designated levels of change including symptom/situational, cognitions, and
intra/interpersonal conflicts (Prochaska, 1995).

Feminist narrative therapy (FNT) is an evolving approach to narrative

therapy (White & Epston, 1990) that incorporates feminist principles. Grounded in
a constructionist perspective, FNT posits that individual understandings of reality
are socially constructed through stories used to make meanings out of everyday
life experiences (Brown, Weber, & Ali, 2008; Lee, 1997). Practitioners of FNT
postulate that women’s self-narratives are embedded in gendered stereotypes and
gendered scripts, influenced by the dominant culture (Banker, 2010; Gremillion,
2004; Lee, 1997). The approach is critical of the power dynamics that devalue
International Journal of Integrative Psychotherapy, Vol. 9, 2018 57
women’s voices and therefore intentionally strives to understand a woman’s
unique narrative, in an effort to avoid universalizing women’s experiences in the
counseling process (Lee, 1997).

Person-Centered Therapy (PCT) is a model of psychotherapy that shares

concepts with humanistic and existential perspectives (Corey, 2016). PCT
assumes that clients have an innate ability to change by altering their attitudes
toward their problems (Rogers, 1979). Mental health professionals practicing PCT
value their client’s worldview and position the client as the expert (Bohart, 2012).
PCT supports the client’s capacity for self-change by creating a growth-promoting
climate through the instillation of three core conditions (a) empathy, (b)
congruence, and (c) unconditional positive regard (Rogers, 1979).

Rational Emotive Behavioral Therapy (REBT) is a form of psychotherapy

oriented around cognitions and behaviors. Mental health professionals practicing
REBT attend to clients’ thinking, judging, deciding, analyzing, and actions in
therapy (Ellis, 1996; Corey, 2016). Clinical problems are largely viewed as the
result of irrational beliefs that consist of demands that clients place on themselves,
others, and life conditions (Ellis, 1996; Guterman & Rudes, 2005). REBT advances
that clients intensify their distress by the way they interpret situations. Mental
health professionals who practice REBT utilize various techniques to promote
positive change such as challenging absolutist beliefs, behavioral tasks,
psychoeducation, and imagery exercises (Ellis, 1996).

Theoretical Viability

Literature has indicated that constructs from FNT, PCT, and REBT can be
coherently integrated into the therapeutic process. PCT has been most prominent
in demonstrating that the therapeutic relationship is essential to the process of
change (Erskine & Trautmann, 1996; Prochaska, 1995). FNT utilizes PCT’s three
core conditions of empathy, congruence and unconditional positive regard to build
an egalitarian therapeutic relationship (Brown & Augusta-Scott, 2007). Both FNT
and PCT use the client’s frame of reference to promote empowerment and self-
directed change (Bohart, 2012; Brown et al., 2008). While sharing similar
principles, FNT extends PCT by allowing the mental health professional to be an
active facilitator in the therapeutic process (Lee, 1997). Additional researchers and
practitioners have supported the active role of the therapist (see Erskine, 2015). A
feminist narrative perspective also emphasizes clients’ strengths and allows for the
integration of additional techniques to raise clients’ consciousness of their ability
to resolve troublesome issues (Brown et al., 2008).
International Journal of Integrative Psychotherapy, Vol. 9, 2018 58
 Key principles from PCT are utilized in REBT as well. Practitioners of REBT
advise that helping professionals unconditionally accept their clients, as in PCT
and FNT, as a precursor to encouraging clients to unconditionally accept
themselves (Ellis, 1996). REBT, however, expands the concept of acceptance by
actively-directly teaching clients ways to unconditionally accept themselves,
others, and life conditions that they cannot control (Ellis, 1996). All three theories
uphold the constructionist belief that there is no absolute way of determining reality
(Dryden & David, 2008; Ellis, 1997; Lee, 1997; Rogers, 1979). Similar to FNT,
REBT posits that clients should be flexible in their interpretations of ideals based
on dominant society and underscore how specific interpretations can lead to self-
helping or self-defeating behavior (Brown et al., 2008; Ellis, 1997; Lee, 1997).

Case Illustration

The following clinical case offers an illustration of how the integration of

FNT, PCT, and REBT can be facilitated in a short-term therapy framework. The
client’s identifiable information is modified in accordance with the American
Counseling Association’s (ACA) ethical standards (ACA, 2014). The case
conceptualization and session progression are documented below.

The Client

Anna, a 37-year-old female, received psychotherapeutic counseling

services at a private counseling practice. Anna was college-educated and had
been gainfully employed for nine years. She was in a two-year romantic
relationship with a male partner. She expressed that her co-workers and close
friends recommended that she seek counseling, but she avoided following through
on referrals for a year, stating she did not “like getting help.”

The Mental Health Professional

Anna was assigned to a female mental health practitioner (the primary

author, referenced hereby as counselor), who was a Licensed Professional
Counselor with experience in clinical mental health. The counselor supported
egalitarian, strength-based therapies that emphasize clients’ inherent strengths
and respect clients’ self-definitions of reality (Lee, 1997; Ellis, 1997; Moursund &
Erskine, 2004; Rogers, 1979). The counselor supported the concept of sharing
power with the client and owned the privilege of being trained in multiple
therapeutic approaches that can facilitate the change process (Lee, 1997). An
International Journal of Integrative Psychotherapy, Vol. 9, 2018 59
integrative approach that demonstrated flexibility in incorporating insights and
techniques from empirically supported theories to meet the client’s specific needs
was most valued by the counselor. It was the counselor’s belief that
psychotherapeutic change can be mediated by many methods ranging from self-
directed change (White & Epston, 1990), the use of the therapeutic relationship
(Erskine, 2015; Rogers, 1979), the use of teaching behavior tasks, or the use of
psychoeducational material (Ellis, 1997). Finally, the counselor believed mental
distress can originate from various origins such as biological/intrapersonal
conditions or sociocultural factors (Ellis, 1997; Erskine, 2015; White & Epston,
1990). Each approach chosen (i.e., FNT, PCT, and REBT) has constructs that are
congruent with the counselor’s personal and therapeutic philosophy.

Initial Clinical Interview

During the initial clinical interview, the counselor utilized a subjective

method of history taking (Carrey, 2007). A subjective approach involves allowing
clients to share their personal accounts about experiences they perceive to
influence their overall health and wellbeing (Carrey, 2007). The counselor engaged
Anna in a collaborative conversation centered on reasons for seeking counseling,
personal and family history, and counseling preferences. The counselor paid
special attention to the language Anna used while providing her history and noted
Anna’s strengths and availability of resources (Lambie & Milsom, 2010). The
counselor provided a synopsis of the theoretical orientations that guided her
practice and asked Anna to complete the Stages of Change Scales
(McConnaughy, DiClemente, Prochaska, & Velicer, 1989).

Primary Presenting Issues

From information attained through the clinical interview, Anna’s primary

presenting issues were identified as (a) resistance to seeking help, (b) upholding
absolutist beliefs and demandingness of others, and (c) self-depreciation. The
counselor speculated Anna was in the precontemplation stage (see Norcross,
Krebs, & Prochaska, 2011). The precontemplation stage is a stage in which clients
are unaware or underaware of their problems and would reasonably demonstrate
resistance or apprehension to supportive services due to having less awareness
of problems (Norcross et al., 2011; Prochaska, 1995). Gold (2008) proposed that
a client’s resistance may reflect a narrative that consists of beliefs about the
legitimacy of seeking help or an opposition to problem solving with others. In order
to move Anna from the precontemplation stage and get her to commit to therapy,

International Journal of Integrative Psychotherapy, Vol. 9, 2018 60

the counselor anticipated she would need to address Anna’s beliefs associated
with receiving and giving help (Gold, 2008; Prochaska, 1995).

Secondly, the counselor considered it important to address Anna’s problem-

saturated story. Anna reported feelings of self-blame, unhappiness, resentment,
and embitterment, which may have been resultant of distress due to positioning
herself in a gendered prototype. Anna’s dominant narrative appeared to be based
on absolutist beliefs that stemmed from gendered roles prescribed by the dominant
culture.

Finally, the counselor addressed Anna’s self-deprecating attitude. Anna

stated she had not received the treatment she felt she deserved in most of her
relationships. As a result of her dominant narrative, Anna unremittingly helped
others and suppressed her own needs. She appeared to exhibit low self-
entitlement and the counselor believed she could potentially benefit from
recognizing her voice and personal power in an expectation that such awareness
would change her pattern of behavior.

Linking Presenting Issues to Therapeutic Approaches

The counselor expected Anna to exhibit resistance in the initial stages of

counseling due to her delay in seeking mental health services that may possibly
have been related to her under-awareness of her problems. The core conditions
of PCT could potentially be helpful to use to establish trust in the counseling
relationship (Gold, 2008; Prochaska 1995). Anna reported she had to “grudgingly”
care for her younger siblings. Anna also referenced that she acted like “Mother
Theresa” in her current relationships. Overall, Anna’s personal narrative from past
to present revealed that she positioned herself in a nurturing role, given the many
examples she provided of supporting her boyfriends, co-workers, and friends.
From a feminist narrative perspective, the counselor postulated that Anna’s self-
concept was interwoven with the stories of others regarding a woman’s role in
relationships. A feminist narrative approach would help Anna develop an
understanding of how dominant discourse may have influenced her problem
description and help Anna to reconstruct a more preferred personal narrative
(Brown et al., 2008; Lee, 1997).

From a REBT perspective, the counselor proposed that Anna had specific
absolutist beliefs reflected in her dominant narrative of feeling obligated to help
others. Thus, it could be implied that Anna was exacerbating her distress by
upholding the belief that she should and must subjugate her needs and wants to
International Journal of Integrative Psychotherapy, Vol. 9, 2018 61
appease others. REBT was useful to assist Anna in generating more flexible
interpretations of the underlying beliefs that guide her actions. REBT also provides
techniques that aid counselors in teaching methods to reduce distress and
recognize patterns of behavior.

Relatedly, Anna displayed a demandingness that others should live by her

standards. For example, Anna stated she had “insisted” that a boyfriend stop using
drugs and told a boyfriend what he “should know” about himself. REBT suggests
that demanding others must change is a self-defeating pattern of behavior (Ellis,
1994). Through the use of REBT perspectives, the counselor anticipated she could
teach Anna the philosophy of Unconditional Other Acceptance (Ellis, 1996) and
help Anna accept aspects of others that she cannot change.

Primary Clinical Themes

Two clinical themes framed Anna’s presenting problems: (a) Anna

constructed her personal narrative from the position of received knowing (see
below), thus the development of her own voice and personal value system has
been restricted (Belenky, Clinchy, Goldberger, & Tarkle, 1986) and (b) Anna’s
moral stage of development reflected an under-awareness of her pattern of
behavior which prompted Anna to subjugate her wants to appease others (Gilligan,
1982).

Women’s ways of knowing theory was used to conceptualize how Anna’s

knowledge and meaning-making systems were constructed. The theory
designates a knowledge perspective termed received knowing in which a woman’s
knowledge is constructed by identifying with and conforming to social norms,
gender roles, and the expectations of others (Belenky et al., 1986). Received
knowers model themselves after the sociocultural ideals of what a woman should
be as communicated by outside entities, such as religious groups, family members,
and other authorities (Belenky et al., 1986). Anna appeared to construct her
knowledge and beliefs from a received knowing position as evidenced by her
reports of obligations to care for others, having to be a “goody two shoes,” and
receiving the message that she would “go to hell” if she demonstrated behavior
that did not conform to the social norm for women.

Carol Gilligan’s “ethics of care” theory was used to frame the clinical theme
in relation to Anna’s moral and personality development. Ethics of care refers to
the perspective that people value relational and context-bound approaches
regarding moral development and decision making (Gilligan, 1982). Gilligan
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postulated that a woman’s development is heavily influenced by the values of her
family and friends (Gilligan, 1982). Accordingly, a woman may center her thoughts
and actions on the needs and interests of others. Anna’s development appeared
to align with the stage Gilligan referred to as “overemphasis on others.” Gilligan
asserted that women in this stage equate goodness with self-sacrifice and often
suppress their personal needs. Anna displayed behaviors comparable to this
stage, as evidenced by stating that she infrequently received mutual respect and
satisfaction in her relationships and sharing how she obligated herself to help
others while being reluctant to accept help in return. Gilligan speculated that a
woman may exhibit destructive behaviors if her wants are suppressed long-term.

Proposed Counseling Goals

The goals and expectations of therapy were negotiated and co-constructed

(Brown et al., 2008) between the client and the counselor. The first counseling goal
was to encourage Anna to revise her relationship with her problems and develop
a more preferred story. The aim of this goal was to increase Anna’s awareness of
the misogynous metanarrative that had possibly molded her dominant story (Lee,
1997). The anticipated outcome was that Anna would be able to identify personal
values and strengths to re-construct a preferential and empowering personal
narrative.

The second goal was to help Anna develop skills (e.g., assertive
communication skills) to establish mutually satisfying relationships. The aim of this
goal was to increase Anna’s ability to identify self-helping and self-defeating
behavior patterns (e.g., absolutist thinking, demandingness, self- deprecating
attitude) and move toward positive change.

Session Progression

Sessions were scheduled weekly and progressed to bi-weekly as the client

moved from the precontemplation stage to becoming more active and committed
to therapy (Prochaska, 1995).

Session 1. During the first session, the counselor utilized active listening
skills, empathic responses, and conveyed unconditional positive regard to create
a nurturing environment (Ngazimbi, Lambie, & Shillingford, 2008). The counselor
invited Anna to share about herself. Anna disclosed that she was apprehensive to
seeking professional services due to stigmas associated with seeking mental
International Journal of Integrative Psychotherapy, Vol. 9, 2018 63
health services. The counselor honored her feelings and helped her to normalize
her thoughts regarding seeking professional support (Gold, 2008; Erksine, 2015).
The counselor and Anna negotiated how they could integrate Anna’s preferred
style of being with the counselor's style of helping (Gold, 2008). Anna stated she
did not want to feel judged in therapy. The counselor assured Anna that she would
value her perspectives. The counselor also shared with Anna the philosophy of the
feminist narrative approach which values the subjective experiences of women
(Lee, 1997). The counselor did not engage in further questioning during this
session to avoid overwhelming Anna as she worked through resistance. The
counselor asked Anna to think about areas she wanted to explore in the next
session.

Between session activity: The counselor wrote and mailed Anna a letter thanking
her for attending the session and being willing to share her story. Writing letters
personalizes the relationship and reduces professional distance with clients (White
& Epston, 1990).

Sessions 2-3. The counselor checked-in by asking Anna to share her

thoughts from the previous session. The counselor asked Anna if she felt
comfortable with the method of questioning because this would be her primary way
of understanding Anna’s experiences. Anna stated she was open to questioning.
The counselor posed circular questions from an exploratory position to
demonstrate that she does not imply any privileged access to the truth and
genuinely sought to understand Anna’s experiences (Erskine & Trautmann, 1996;
Monk, 1997). The counselor asked Anna to share more of her story and reflect on
identifying her presenting problem. Anna disclosed stories about her childhood,
experiences in her workplace, and details about her romantic relationships. The
counselor paid close attention to Anna’s language and was careful to utilize Anna’s
language when paraphrasing and providing feedback (Lee, 1997). Anna identified
her problem as assuming the helper’s role, which has impacted nearly all of her
relationships. Anna stated that she frequently felt feelings of unhappiness,
resentfulness, embitterment, and dissatisfaction, although at times, she truly
enjoyed helping others in need. At the conclusion of the sessions, the counselor
asked Anna to reflect on how the problem she identified had influenced her life and
document them in a journal.

Between session activity: Journaling.

Sessions 4-5. Anna progressed to the preparation stage as evidenced by

her journaling instances in which she was aware that problems existed and
International Journal of Integrative Psychotherapy, Vol. 9, 2018 64
considered ways to address the issues (Prochaska, 1995). The counselor
continued to explore Anna’s story and engaged Anna in externalizing
conversations to help her separate herself from the problem (Lee, 1997). The
counselor explored the meaning that Anna attached to accepting and maintaining
her helper’s role, in order to gain a greater depth of understanding. As Anna shared
her story, she became more aware of how the problem was affecting her life and
relationships. The counselor supported Anna in this process by co-identifying
areas in Anna’s story in which being the helper may have impacted her decision
making. Anna realized that she chose to move to a deteriorating home, in a drug-
laden neighborhood, so that she could attract people in need, even though with
her yearly salary she was able to afford to live in another location. Anna also
acknowledged that she sought out her romantic partners in the community where
she lived, as this is the reason why she has often attracted partners with substance
abuse issues. By session six, Anna’s awareness of how the helper’s role had
affected her life was demonstrated by her ability to provide more details of how she
had passed-up opportunities to date men with monogamous intentions who shared
similar values and interest as her. The counselor mapped the influence of Anna’s
problem to support Anna in exploring her dominant story (White & Epston, 1990).

Between session activity: Anna wrote about the pros and cons of maintaining the
helper’s role in her journal. The counselor wrote Anna a letter to support her efforts
in deconstructing her story as a means of client-empowerment.

Sessions 6-7. Anna demonstrated that she was in the contemplation stage
by reporting that she had made a positive change by choosing not to give money
to her boyfriend for drugs. Anna stated that she was ready to make more changes
in her life because she had gotten in trouble at work. Anna also stated that her
boyfriend was dating one of her friends and she was confused as to why she was
still interested in seeing him.

The counselor used these sessions to educate Anna on REBT’s constructs

of absolutist thinking and demandingness and highlighted how these beliefs may
have contributed to Anna’s discontent in relationships. The counselor reinforced
how Anna’s prior absolutist beliefs about maintaining the helper’s role may have
derived from the wider social context and thus inhibited her willingness to prioritize
her own needs (Lindsley, 1994). The counselor helped Anna identify instances in
which she held absolutist beliefs and demanded others to change. Anna was
educated in various ways that the moral and personality development of women
was often influenced by societal standards (Brown & Augusta-Scott, 2007; Gilligan,
1982). The counselor assisted Anna in generating more flexible interpretations of
International Journal of Integrative Psychotherapy, Vol. 9, 2018 65
how she could build her self-esteem and self-efficacy and help others without
having to suppress her own needs. The counselor modeled assertive
communication skills. The counselor engaged Anna in the process of re-telling her
story with the inclusion of ways that Anna can value herself in her new story. The
counselor encouraged Anna to use her personal experiences and self-ideal as part
of re-telling her story to avoid adopting generalizations of womanhood from wider
societal contexts.

Between session activity: The counselor asked Anna to identify historical unique
outcomes (White & Epston, 1990) in order to recall events from her past that
contradict how the problem has affected her life and relationships. The counselor
asked Anna to document these situations and strategies she used to successfully
resolve these situations in her journal. The counselor provided Anna
psychoeducational material related to communication skills, building self-esteem,
and coping with stress to illustrate how distress influences the body, thoughts,
feelings, and behavior (Perlman, 2002; Ussher, Hunter, & Cariss, 2002).

Sessions 8-9. Anna was fully engaged in the action stage as evidenced by
her ability to begin to re-author her story. Anna used more positive language and
asserted her own interpretations. She stated that she used assertive
communication skills in a conversation with her romantic partner. She reported that
she was able to express to him that she would no longer tolerate him dating her
friend and requested that he value her as his girlfriend. Anna displayed the capacity
and agency to intervene in her own life and relationship as she reconstructed her
story in a more preferred fashion (Brown et al., 2008). Anna continued to identify
current unique outcomes. The counselor reinforced Anna’s progress by asking her
to continue to journal her experiences throughout the re-authoring process. The
counselor proposed that together she and Anna could create a self-help book of
personal success stories with the journal entries and letters that were written
throughout the counseling process. Writing success stories transforms the
relationship of the person or problem as well as enables a client to self-reflect
should the problem re-emerge (White & Epston, 1990).

Between session activity: Anna started to gather content for her self-help book.

Sessions 10-11. Anna and the counselor worked on composing her self-
help book in session. The self-help book referenced Anna's former problem-
saturated story provided contradictions to the dominant plot and documented new
interpretations of the problem (White & Epston, 1990). The counselor worked
toward identifying an audience to reinforce Anna’s progress. Narrative therapy
International Journal of Integrative Psychotherapy, Vol. 9, 2018 66
practitioners believe that new stories take hold when there is an audience to
appreciate and support them (White & Epston, 1990). Anna expressed that she
had been working with elderly persons in the community. The counselor engaged
in planning ways to connect Anna with a network of community leaders who shared
the same passion for caring for the elderly. The counselor informed Anna that the
group of community leaders had a structured process for raising money for elderly
persons by hosting weekly fundraising activities. The counselor considered this
group ideal for Anna because she would have a chance to pursue her passion for
helping people in a more constructive manner.

Between session activity: The counselor linked Anna to the community

organization.

Session 12-13. Anna expressed how her participation in the community

humanitarian group was helpful because she was involved in a worthy cause in
which she felt valued by others. Anna stated that she was ready to terminate
therapy because she had a better understanding of how she had accepted and
maintained the helper’s role and how this influenced her wellbeing. Anna stated
that she had learned how to value and voice her feelings by setting limits in her
relationships. Anna also stated that she did not demand others to live by her
standards and recognized that everyone had their own reality.The counselor
proposed that a definitional ceremony would provide a framework to facilitate a
meaningful closure to the therapeutic relationship (Lenz, Zamarripa, & Fuentes,
2012). A definitional ceremony offers clients the opportunity to tell parts of their
stories to a carefully chosen audience - audience members respond to the stories
by emphasizing the positive impact of the stories, garnering witnesses to the
clients’ worth, vitality, and being (Leahy, O’Dwyer, & Ryan 2012; Lenz et al., 2012;
White, 1995). Anna stated that she would make arrangements for the ceremony
and the counselor agreed to attend.

Between session activity: Anna chose to conduct her definitional ceremony during
her humanitarian group meeting. During the ceremony, Anna shared about the
development of a new narrative toward helping, changes in valuing herself and
others, her passions, and readiness to accept new responsibilities (Lenz et al.,
2012).

Termination session and follow-up. Anna was in the action stage by the time of
termination of therapy as evidenced by the reports in her definitional ceremony.
Anna verbally reinforced that she felt validated and supported in her relationships.
Anna agreed to use the self-help book as a means of reflection to continue
International Journal of Integrative Psychotherapy, Vol. 9, 2018 67
progress once therapy was concluded. Anna stated that she felt more empowered
to follow her own destiny and more confident in her decision making. The
counselor mailed Anna a certificate of appreciation for completing therapy and
welcomed her back if additional work was needed. The follow-up session was
conducted two months after termination. Anna stated that she was still involved in
the humanitarian group weekly. Anna stated that she was having fewer issues at
her job and that her romantic relationship had improved. Anna also stated that she
was planning to move to another neighborhood that would be more conducive to
her personal development.

Assessment of Intervention Effectiveness

Anna’s progress was assessed by her ability to start re-authoring her life
story. By session termination, Anna demonstrated the ability to recognize the
sources of her problem and used a more empowering narrative. Intervention
effectiveness was also evaluated by Anna demonstrating the ability to recognize
risky thoughts such as absolutist thinking and demandingness and by her ability to
use assertive communication skills to improve her relationships.

The counselor also administered the post session Stages of Change

Scales, to measure Anna’s progression through the stages of change since
beginning therapy (McConnaughy et al., 1995). The counselor concluded that
Anna had successfully navigated from the precontemplation stage to the action
stage based on her pre and post responses on the scale.

Limitations

Literature has shown that each approach used has specific limitations. For
example, PCT has been criticized for its non-directedness (Kahn, 1999). FNT’s
emphasis on subjectivity and relativity has been critiqued by various scholars
(Brown & Augusta-Scott, 2007) and REBT has received much criticism for its
forceful nature (Guterman & Rudes, 2005). Despite these limitations, all three of
the therapies are identified as successful in managing emotional distress in relation
to psychological and emotional issues (Banker, 2010; Dryden & David, 2008;
Proctor, 2008). Last, it is important to note that the case illustration encompassed
a short-term counseling framework spanning 13 weeks and caution should be
applied in generalizing the content to shorter or longer counseling processes as
the beliefs, attitudes, behaviors, and resources of clients and counselors vary.

Implications for Practice and Conclusion

International Journal of Integrative Psychotherapy, Vol. 9, 2018 68
 This article illustrates how mental health professionals can integrate
feminist, cognitive-behavioral, and person-centered principles and techniques into
the therapeutic process. Using a collaborative counseling relationship grounded in
trust, empowerment, and compassion, mental health practitioners can help clients
to claim their own voice and individuality and move toward positive change (Crumb
& Haskins, 2017; Moursund & Erskine, 2004). However, when using integrative
approaches, it is important to consider that clients may not be receptive to the
principles espoused in each theory. Mental health professionals should be careful
not to pressure clients to adopt their personal values, which may contradict a
client’s belief values and belief system. Mental health professionals should engage
in the process of practitioner reflexivity, in which the professional consciously
separates his or her personal views from the clients’ worldviews (Lee, 1997).
Attending to the client’s subjective experiences and establishing transparency
throughout the therapeutic process is imperative.

Furthermore, clients and mental health professionals may not have

consensus on issues such as (a) relative preferences for stability versus change,
(b) investment in the change process, or (c) willingness to consider alternative
explanations of the presenting problem (Gold, 2008). These issues can potentially
defeat attempts to resolve the client’s presenting problem. Therefore, it is essential
that mental health professionals remain flexible in their therapeutic approach. In
order to enhance a client’s receptiveness to therapy, mental health professionals
should utilize a variety of methods such as valuing the client’s thoughts and
feelings, providing insight, providing psychoeducational material, and teaching the
client communication and behavioral techniques, all of which are accomplished
through therapeutic flexibility and integration (Erksine, 2015; Moursund & Erskine,
2004).

Author:
Dr. Loni Crumb is an Assistant Professor in the Counselor Education Program in
the Department of Interdisciplinary Professions at East Carolina University and a
Licensed Professional Counselor. Dr. Crumb received her Ph.D. in Counseling and
Student Personnel Services from the University of Georgia, M.A. in Education and
Community Counseling from Clark Atlanta University, and B.A. in Psychology from
North Carolina State University. Her research interests include counseling in rural
areas, promoting retention and persistence of underserved students in higher
education, college student mental health, and social justice and multicultural
training.
International Journal of Integrative Psychotherapy, Vol. 9, 2018 69
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