Rational-Emotive Behavior Therapy
I have been using REBT as my primary treatment approach for over 18 years as a therapist. I was first introduced to this model of therapy in college and in more detail in graduate school. Initially, I was reluctant to use REBT because I felt it was impersonal and too directive. I was rather put off by Albert Ellis’s way of challenging clients in such a confronting way demonstrated in the instructional videos I watched in my graduate school training. I was inclined to a more gentle, “Rogerian” approach with my clients. However, I soon found the benefits of REBT to be profound as I began to understand it and use it consistently.
I have found REBT to be an effective approach with a wide variety of clients suffering with various problems. I have used it with clients dealing with sexual abuse, eating disorders, substance dependence, and many other difficult issues. As I describe in the case illustration, I have personally benefited from REBT in overcoming panic attacks.
My experience has been that many therapists have a basic understanding of REBT, especially the ABC model, but few seem to understand it comprehensively or use it consistently with their clients. It seems that the behavioral homework so vital for REBT to be effective is so often minimized or overlooked. Teaching your clients the ABCs is only the beginning of treatment with REBT. One of the keys to REBT is to help clients wrestle through the entrenched belief systems contributing to their emotional disturbances. This often requires time, hard work, and a complete commitment to the process from the client.
In this continuing education course, I have attempted to provide a basic review of REBT and its practical application to a few disorders. I have focused on REBT, but I have also added some material on Cognitive Therapy at the end since the two models substantially overlap. I hope you benefit from the course and I thank you greatly for using the site.
Rational-Emotive Behavior Therapy (REBT) is a form of cognitive behavioral psychotherapy (CBT) and psychoeducation based on the premise that by changing patterns of thinking, one can achieve dramatic improvements in emotional and behavioral health. Ellis (1994) characterizes REBT’s approach and goals by saying that REBT is not, “…primarily interested in helping people ventilate emotion and feel better, but in showing them how they can truly get better, and lead to happier, non-self-defeating, self-actualized lives.”
CBT has been shown in numerous studies to be effective for diverse problems. (David, Szentagotai, Eva & Macavei, 2005) A portion of CBT research has specifically evaluated REBT outcomes. (Leichsenring, Hiller, Weissberg, & Leibing 2006)
David, Szentagotai, Eva & Macavei (2005) state that, “REBT is not only a clinical theory useful for clinical populations, but also an educational system with implications for nonclinical and subclinical populations (e.g., depressed mood, lack of assertiveness, test or speaking anxiety) who have an interest in self-help materials and personal development.”
REBT, first called rational therapy, and then rational-emotive therapy (RET), was developed in the 1950’s by Dr. Albert Ellis, a psychoanalytically trained psychologist. He began developing REBT when he came to feel that his patients were progressing too slowly using psychoanalysis. At about the same time, psychiatrist Aaron Beck developed cognitive therapy (CT). REBT and CT were the first of the therapies that grew into the cognitive behavioral therapy movement. Ellis refers to the 1980’s and 1990’s, when cognitive approaches became quite widespread, as, “the cognitive revolution.” (Ellis, Bernard, 2006)
When Ellis first introduced these ideas in 1955, he was scorned by psychology, but by 1982, a poll of psychologists placed him above Freud as having influenced the field of psychology. (Kaufman, 2007)
The key differences between REBT and earlier approaches are its “de-emphasis on early childhood,” emphasis on deep philosophic change and scientific thinking,” and the “use of psychological homework.” (Ellis, 1994)
Cognitive approaches dramatically expanded our conception of mental health treatment beyond a purely behavioral approach and emphasis on the unconscious, to one in which the conscious and rational abilities of people are emphasized, and in which conscious and nearly-conscious beliefs are treated as meaningful dynamics that can be addressed directly.
REBT holds that dysfunctional beliefs from early childhood do not automatically sustain themselves. A dysfunctional belief system is dynamic and requires maintenance. This means that it is vulnerable to confrontation through means such as rational analysis and other methods of REBT. Thus, the goal of deep philosophical change refers to alteration of dysfunctional beliefs that have a chronic negative impact. When deeply held beliefs change, this results in a change in philosophy because the most damaging dysfunctional beliefs comprise a pattern of thinking about one’s life, identity, or the world. Scientific thinking is in the picture, because, as in science, patients learn to test their thinking as a scientist would test a hypothesis. This is done with patients that range from bright and gifted, to psychotic and cognitively impaired.
In supporting the idea of homework in REBT, Ellis (1994) asserts that work is required to make these profound changes into a durable way of life. He is not content with mere insight, saying, “there is usually no other way…to get better but by their continually observing, questioning, and challenging their own belief-systems, and by their working and practicing to change their own irrational beliefs by verbal and behavioral counter-propagandizing activity.”
REBT is both a collection of methods and a theoretical orientation that embraces the biopsychosocial model that posits interplay of biology, psychology and sociology in shaping human behavior and experience.
Although it is part of the larger movement of cognitive behavioral therapy, it stands as having originated radical characteristics. These include dispensing with self-evaluation. Rather than attempting to improve client self esteem, REBT trains clients to refrain from global evaluations of self and other. This provides an important inroad into the dramatic and destructive reactions that REBT serves to eliminate.
The focus on secondary disturbances, such as feeling extreme guilt or shame about their problem, allows REBT to address the snowballing or feedback effect of this dynamic. This can greatly contribute to early emotional stabilization and pave the way for successful treatment.
The anxiety model, that includes ego anxiety and discomfort anxiety, is a cornerstone to REBT. These anxieties are treated as discrete dysfunctions that are addressed by altering the client’s beliefs.
The hallmark of REBT is the dramatic improvement in emotions and behavior that results from exclusively altering “core beliefs.” The methods of REBT revolve around that intention.
Dr. Ellis died at the age of 93 in his home above the Albert Ellis Institute in July of 2007. He was born September 27, 1913. He held a Ph.D. in clinical psychology from Columbia University. Because of the impact of REBT, he is considered the grandfather of cognitive-behavior therapy (CBT). He founded the Albert Ellis Institute (formerly, the Institute for Rational-Emotive Therapy) in New York City in 1959. He received numerous awards from professional societies, including Humanist of the Year Award of the American Humanist association. He received the major award of the American Psychological Association for Distinguished Professional Contributions to Knowledge. He published more than 75 books and over 700 articles on psychotherapy and personal issues.
His New York Times obituary stated, “Irreverent, charismatic, he was called the Lenny Bruce of psychotherapy. In popular Friday evening seminars that ran for decades, he counseled, prodded, provoked and entertained groups of 100 or more students, psychologists and others looking for answers, often lacing his comments with obscenities for effect.” (Kaufman 2007)
Ellis also published books and articles on sexuality that were so radical for their time that members of the American Psychological Association complained. He collaborated with Kinsey in studying human sexual behavior and was considered a sexual liberationist. (ibid)
Ellis (1994) expresses a key belief of REBT and compares it with Greek stoicism, saying, “Like stoicism, a school of philosophy which existed some two thousand years ago. Rational emotive behavior therapy holds that there are virtually no good reasons why human beings have to make themselves very neurotic, no matter what kind of negative stimuli impinge on them.”
Ellis considers the Greek Roman stoic Ecpictetus to be one of the greatest fathers of cognitive restructuring. Ecpictetus expressed a central belief of REBT when he said, “"Man is disturbed not by things, but by the views he takes of them."
Ellis states that the influence of Ecpictetus led to the principles on which Marcus Aurelius, a Roman emperor in the second century, based his life. These principles, Ellis points out, are embodied in Aurelius’ book Meditations. (Aurelius 2006) In the writings of Aurelius, one can find many ideas that are in keeping with REBT, along with various beliefs of the times, and many references to contemporary and historical figures. Consider this advice from Aurelius, in updated language and paraphrasing from an earlier translation:
People will continue to do unsettling things. Even hanging yourself wouldn’t change that. First, don’t let this bother you, because all things good and evil happen according to the nature of the universe. All things end before long, and no one will be remembered forever. Second, focus on the actual situation in depth. At the same time, keep in mind your identity as a person dedicated to being a good person, and stay true to what your nature requires of you as a person. Don’t be diverted from what you stand for, that is, from the principles that you support. In that sense, exclusively communicate in the way you truly feel is most just, and only in a kind, modest way, without hypocrisy.
Think of yourself as being fit to speak your mind and to act in harmony with nature. Don’t let other peoples’ negative opinions deter you. If you know that a course of action is correct and honest, then don’t let anyone’s attitude stop you from taking it. Be persistent instead of undervaluing yourself so much that you end up discouraging yourself and losing your sense of commitment. As far as the naysayers are concerned, you can see that they have a rational aspect that rules over them, and are inclined to do what makes sense to them. Don’t stop and become distracted by them. Instead, continue on your straight path, where your own nature, and
the nature that we all share, leads you. Remember that the way of both of these is really one path.
Effectiveness: Clinical Application and Research
REBT has been subjected to research, showing good results with many diagnostic and outcome measures. (Leichsenring, Hiller, Weissberg, & Leibing 2006) Many more studies support the use of CBT than REBT, because CBT is a larger rubric that is more likely to be researched. In CBT studies, at least some REBT principles are employed, but it is not possible to evaluate the degree of fidelity with REBT. Some studies attempting to distinguish between various types of CBT in terms of effectiveness have concluded that such differences have not been demonstrated.
The following disorders and non-clinical problems, drawn from Froggatt (2005) are commonly accepted as appropriate clinical applications of REBT. Research specifically referencing REBT are noted here, but this is not a complete list.
- Anxiety disorders, including PTSD
- Social anxiety (Mersch, 1995)
- Eating disorders, addictions, and impulse control disorders
- Anger management and antisocial behavior
- Personality disorders (Leichsenring & Leibing, 2003)
- Sexual abuse recovery
- Coping with chronic health problems, a physical disability, or a mental disorder
- Pain management
- Stress management
- Child or adolescent behavior disorders
- Relationship and family problems
- Personal growth
- Workplace effectiveness
- Type A Behavior (Möller & Botha, 1996)
David, D., Szentagotai, A., Eva, K. & Macavei, B. (2005) reported on the results of two meta studies specifically on clinical application of REBT. Over 300 studies were involved. The first list, Diagnostic Category, shows those diagnostic categories that showed good effect sizes. The second list does this for studies reporting outcome measures not necessarily tied to diagnoses.
- Anxiety (e.g., interpersonal, speech)
- Phobia (e.g., simple and complex)
- Somatic/emotional (e.g., stuttering, overweight, erectile failure, chronic heart disease, home dialysis, asthma, insomnia, migraine)
- Neurotic (e.g., lack of assertiveness depression, behavior problems, potential for dropping out of school, achievement problems)
- Diverse (e.g., rage, type A behavior, school children’s emotional adjustment, well-being)
- Unclassified (e.g., sub-clinical problems, problems that do not fit a well-defined clinical category)
- Performance and behavior (physiological tests of anxiety-heart rate, EEG, pulse, electrodermal response, behavioral tests of anxiety, number of pounds lost in weight reduction)
- Standard measures (e.g., irrational beliefs, depression)
- Physiological measures only (e.g., heart rate, pulse, EEG, electrodermal response)
- Rest category (e.g., self-esteem, well-being, social desirability)
- Unclassified--do not fit the other categories--(e.g., various behavioral measures for school/clinical population)
The authors even found that REBT showed strong effect sizes in comparison with other therapies, excluding behavioral therapies, but including, “psychodynamic, gestalt, humanistic, Adlerian, reality therapy, undifferentiated counselling, vocational and personal development counselling.” (ibid)
They drew the following general conclusions: (ibid)
(1) REBT seems to be useful for a large range of clinical diagnoses and clinical outcomes (see Table 2). Interestingly, REBT has proved to have a much larger effect on ‘‘low reactivity’’ outcomes, which do not have an obvious relationship with the treatment (e.g., physiological measures, grade-point average), than on ‘‘high reactivity’’ measures, which have a direct and obvious relationship with the treatment (e.g., IBs). This suggests that the effect of REBT is not due to compliance or task-demand characteristics.
(2) REBT is equally efficient for clinical and nonclinical populations, for a large age range (9–70), and both for males and females.
(3) In general, there is no difference in efficacy between individual and group REBT.
(4) In general, the higher the level of training of the therapist, the greater/better the results of REBT intervention.
(5) Higher numbers of REBT sessions correlate with better outcomes. Higher quality outcome studies have shown greater REBT effectiveness.
REBT Theory of Human Behavior
Cognition as a Basis for Human Behavior
According to REBT, it is what people believe about themselves and their situations that determine how they feel and behave, rather than the situations themselves. REBT also acknowledges the influence of biology on belief system. These two factors are seen as a combination of biological inheritance and life-long learning.
Froggatt (2005) describes fundamental theory of REBT as follows:
The most basic premise of REBT, which it shares with other cognitive-behavioural theories, is that almost all human emotions and behaviours are the result of what people think, assume or believe (about themselves, other people, and the world in general). It is what people believe about situations they face – not the situations themselves – that determines how they feel and behave. REBT, however, also argues that a person’s biology also affects their feelings and behaviours... A person’s belief system is seen to be a product of both biological inheritance and learning throughout life.
Because its founder parted ways with psychoanalysis, and because REBT emphasizes thought patterns, it may appear to exclude the unconscious. Actually, REBT addresses thought patterns that are so habitual and unquestioned, that they are largely unconscious. However, it emphasizes the importance of making these thought patterns conscious along with how they cause destructive feelings and behavior.
To gain durable relief from the emotional and behavioral problems that stem from such thought patterns, one must change the beliefs that are most fundamental to the destructive pattern.
One of the dynamics that confirmed for Ellis that validity of his approach was the vigorous and successful work patients would do in order to change dysfunctional beliefs, once they were helped to perceive them and to understand their significance. This showed Ellis that the other factors that might constrain patients into neurotic behavior were not primary, that dysfunctional, deeply held beliefs were the primary cause of neurotic suffering.
Putting the Rational in REBT
Froggatt (2005) states that REBT refers to the beliefs that comprise dysfunctional thought patterns as irrational beliefs. To emphasize the importance of changing them in order to live a better life, REBT therapists will use the term self-defeating beliefs with patients.
Fundamental Elements of Core Irrational Beliefs
Ellis observed fundamental elements common to all irrational core beliefs. These are an unrealistic demand that the person places upon oneself, others, or the world, to be different than they are, and one of the following: low frustration tolerance, awfulizing, or people rating. (Perkins, 2007)
Three Criteria for Irrational Beliefs
Froggatt (2005) offers the following criteria for irrational beliefs:
1. It blocks a person from achieving their goals, creates extreme emotions that persist and which distress and immobilise, and leads to behaviours that harm oneself, others, and one’s life in general.
2. It distorts reality (it is a misinterpretation of what is happening and is not supported by the available evidence).
3. It contains illogical ways of evaluating oneself, others, and the world: demandingness, awfulising, discomfort-intolerance and people-rating.
Three Core Beliefs, Fundamental
Ellis (2003) boiled down the many irrational beliefs he had observed into three core beliefs that, collectively, embrace them all:
1. "I ABSOLUTELY MUST be thoroughly competent, adequate, achieving, and lovable at all times, or else I am an incompetent worthless person." This belief usually leads to feelings of anxiety, panic, depression, despair, and worthlessness.
2. "Other significant people in my life, ABSOLUTELY MUST treat me kindly and fairly at all times, or else I can’t stand it, and they are bad, rotten, and evil persons who should be severely blamed, damned, and vindictively punished for their horrible treatment of me." This leads to feelings of anger, rage, fury, and vindictiveness and lead to actions like fights, feuds, wars, genocide, and ultimately, an atomic holocaust.
3. "Things and conditions ABSOLUTELY MUST be the way I want them to be and never be too difficult or frustrating. Otherwise, life is awful, terrible, horrible, catastrophic and unbearable." This leads to low-frustration tolerance, self-pity, anger, depression, and to behaviours such as procrastination, avoidance, and inaction.
Twelve Irrational Beliefs
An earlier list of irrational beliefs by Ellis (1994) offers twelve irrational beliefs associated with neurotic adjustment. Although they may overlap in terms of the more condensed three core beliefs above, they serve as excellent examples for learning more about REBT:
1. The idea that it is a dire necessity for adults to be loved by significant others for almost everything they do -- instead of their concentrating on their own self-respect, on winning approval for practical purposes, and on loving rather than on being loved.
2. The idea that certain acts are awful or wicked, and that people who perform such acts should be severely damned -- instead of the idea that certain acts are self-defeating or antisocial, and that people who perform such acts are behaving stupidly, ignorantly, or neurotically, and would be better helped to change. People's poor behaviors do not make them rotten individuals.
3. The idea that it is horrible when things are not the way we like them to be -- instead of the idea that it is too bad, that we would better try to change or control bad conditions so that they become more satisfactory, and, if that is not possible, we had better temporarily accept and gracefully lump their existence.
4. The idea that human misery is invariably externally caused and is forced on us by outside people and events -- instead of the idea that neurosis is largely caused by the view that we take of unfortunate conditions.
5. The idea that if something is or may be dangerous or fearsome we should be terribly upset and endlessly obsess about it -- instead of the idea that one would better frankly face it and render it non-dangerous and, when that is not possible, accept the inevitable.
6. The idea that it is easier to avoid than to face life difficulties and self-responsibilities -- instead of the idea that the so-called easy way is usually much harder in the long run.
7. The idea that we absolutely need something other or stronger or greater than ourself on which to rely -- instead of the idea that it is better to take the risks of thinking and acting less dependently.
8. The idea that we should be thoroughly competent, intelligent, and achieving in all possible respects -- instead of the idea that we would better do rather than always need to do well and accept yourself as a quite imperfect creature, who has general human limitations and specific fallibilities.
9. The idea that because something once strongly affected our life, it should indefinitely affect it -- instead of the idea that we can learn from our past experiences but not be overly-attached to or prejudiced by them.
10. The idea that we must have certain and perfect control over things -- instead of the idea that the world is full of probability and chance and that we can still enjoy life despite this.
11. The idea that human happiness can be achieved by inertia and inaction -- instead of the idea that we tend to be happiest when we are vitally absorbed in creative pursuits, or when we are devoting ourselves to people or projects outside ourselves.
12. The idea that we have virtually no control over our emotions and that we cannot help feeling disturbed about things -- instead of the idea that we have real control over our destructive emotions if we choose to work at changing the musturbatory hypotheses which we often employ to create them.
Discovering Core Beliefs: Three Levels of Thinking
Three levels of thinking helps us understand the patient’s cognitive patterns, and to identify core beliefs. They are inferences, evaluations, and core beliefs, discussed above.
The most superficial is “inferences”. These are a guess or opinion as to what happened. Dysfunctional thinking tends to lead the person to take their inferences as being factual as well as to jump to dramatic negative conclusions. Inferences are not treated directly in REBT, but help the therapist understand the client’s evaluative thinking. By refraining from struggling with what could amount to an endless variety of dysfunctional inferences on the part of the patient, the therapist is more concerned with addressing core beliefs.
On a deeper level are “evaluations”. This is addressed in the next section, and is essentially the significance that the person assigns to a situation or person. It is fairly easy to get to a core belief. For example, if a person infers from their depression that they are worthless, then the demand for inhuman perfection is evident as a core belief.
Dysfunctional Evaluative Thinking
Although one may find a grain of truth in any of the irrational beliefs, they have a style of evaluative thinking that ensure that they will have a destructive effect.
One of these is “demandingness”, which Ellis referred to as “musturbation”. These demands or ‘musts’ can be about the self, others, or the world (situations and events). The things demanded are perceived as “absolute necessities”. (Froggert, 2006), resulting in an intense and uncomfortable reaction when the demands are violated.
Another evaluative aspect is “awfulizing”, where the person exaggerates the significance or consequences of undesirable events, and even aspects of desirable events. This exaggerating eclipses the prospects for creativity and management of the situation in the person’s mind.
Another evaluative aspect is “discomfort intolerance”. In this thinking, the person believes that they are tormented by an undesirable circumstance, or that it is intolerable. The extremity of the reaction and perspective makes it difficult for the person to see ways that they can get through or even improve their circumstance. A dramatic example is of a patient who could not become invested in living until he got over his disappointment that the universe was expanding and cooling.
Finally, “people-rating” involves making an extreme and global evaluation of oneself or others, that is, to apply a negative label to the person as though it encompassed their entire significance. The self-belief of a depressed person that they are “worthless” can be seen as a people-rating response to a demand of the self for inhuman perfection. Such a demand distracts the person from opportunities to get better, thus helping to lock the person into their depression.
Model of Anxiety
Anxiety is fundamental to REBT theory. Ellis distinguishes between two major forms of anxiety. Discomfort anxiety (DA) results from a perceived threat to personal comfort in life coupled with a belief that “they should or must get what they want (and should not or must not get what they don’t want).” (Ellis, 1990) The anxiety is increased by a third requisite, that “it is awful or catastrophic (rather than merely inconvenient or disadvantageous)” (ibid) if they do not experience the desired outcome of what must or must not happen.
The other major form of anxiety is ego anxiety (EA). This results from a similar pattern as DA. In this case, the individual experiences a threat to self worth and believes that, “they should or must perform well and/or be appreciated by others…”(ibid) EA increases their anxiety further through the belief that, “it is awful or catastrophic when they don’t perform well and/or are not approved by others as they believe they should be.” (ibid)
Ellis cites EA as being particularly dramatic, and states that it is a key part of many emotional difficulties, including, “severe depression, shame, guilt, and inadequacy and frequently drives people to therapy (or to suicide).” (ibid) DA, on the other hand, is less dramatic but more common. It acts as a primary cause, or as a secondary factor that creates a vicious cycle in making emotional difficulties more persistent or extreme. In effect, the person may feel anxious about being anxious. The resulting emotional difficulties can include, “feelings of anxiety, depression or shame.” (ibid) As a primary cause, Ellis states that this can trigger anxiety in uncomfortable situations or situations that may be dangerous. The results can include phobias toward potentially dangerous situations such as elevators and heights.
DA can be insidious because of its more subtle nature, and because people tend to attribute the problem to the situation, rather than to their own beliefs. It can be mistaken for free-floating anxiety by clinicians, or simply go unaddressed.
It can also generalize to additional situations, as occurs when a person who is anxious about elevators, and is anxious about being anxious about that, begins worrying about whether they may become afraid of flying, of escalators, or any number of other situations. Such generalization can reach beyond these situations to mere symbols of the situations, or to activities that may involve such situations. For example, a person might begin to live a more limited life because they have become afraid that normal activities may require exposure to the situations that provoke anxiety.
Froggert (2005) describes a fundamental condition that results from demands regarding other people or the world, called “discomfort disturbance.” He states that it comes in two “flavors”, either low frustration tolerance (LFT) and low discomfort tolerance (LDT), that, “…are similar and closely related.”
Low frustration tolerance stems from the belief that one should not experience frustration, that they are entitled to convenience, and that it is terrible when the situation is otherwise. Low discomfort tolerance stems from the belief that one should not have to experience discomfort, that they are entitled to a comfortable existence, and that it is terrible when they are deprived of the comfort they deserve.
Needless to say, people with these anxieties do not generally verbalize such beliefs. However, through REBT treatment they come to see their feelings and behavior as expressions of such beliefs, they are more likely to adopt for constructive forms of self-talk and behavior. These, in turn, support better emotional functioning and greater success.
Discomfort disturbance, Forggert says, is expressed by one or more of the following behavioral and subjective symptoms. Any one of them can be expressed as myriad specific behaviors or states.
'Discomfort anxiety' (emotional tension resulting from the perception that one's comfort (or life) is threatened).
Worrying ('because … would be awful, and I couldn't stand it, I must worry about it in case it happens').
Avoidance of events and circumstances that are seen as 'too hard' to bear or 'too difficult' to overcome.
Secondary disturbance (upsetting oneself about having a problem, e.g. becoming anxious about being anxious, depressed about being depressed, and so on).
Short-range enjoyment - the seeking of immediate pleasure or avoidance of pain at the cost of long-term stress - for example alcohol, drug and food abuse; watching television rather than exercising; practising unsafe sex; or overspending to feel better.
Procrastination - putting off difficult tasks or unpleasant situations.
Negativity and complaining - becoming distressed over small hindrances and setbacks, overconcerned with unfairness, and prone to making comparisons between one's own and others' circumstances.
Ellis feels that animals most likely evolved a high level of need to control their environment in order to meet needs such as safety. This, he says, probably is much of the impetus for discomfort anxiety.
Using REBT to treat panic attacks: Case Illustration
About 15 years ago I had one of the worst panic attacks imaginable. It hit me out of the clear blue with an impact that was overwhelming. I had all of the classic symptoms including shortness of breath, increased heart rate, sweating, dizziness, numbness, feelings of doom, and a general feeling of complete fear. The symptom I remember most was the racing, incoherent thoughts that left me feeling disoriented and completely helpless.
As a therapist familiar with REBT, I was at an advantage to deal with this sudden predicament, but for about the first 30 to 40 minutes into the panic attack, I was too cognitively impaired to do much about it. However, I gradually gained enough lucidity to start processing my plan. First of all, I knew I was dealing with a panic attack. I had never had one before, but knew the symptoms from my graduate school training and some brief experience helping others in counseling deal with the same problem.
My clinical experience told me I was not going to die even though I did have a strong feeling of impending doom. Recognizing that these feelings were not going to kill me and that I was not in imminent danger were important insights in dealing with the problem. Although my thoughts were not completely straight, I realized that my first step had to be to not “awfulize” these panic feelings. This was not easy. The feelings I was experiencing felt bad, very bad, but I had to focus on the fact that they were not going to kill me and that they would eventually pass. I did not rely on positive thinking, but rather factual thinking (an important distinction made in REBT).
To my knowledge, no one has ever had a single, perpetual panic attack that lasted indefinitely. Also, ‘no one has died from a panic attack’ I told myself. I also realized that my main issue was that of control. I could not control the Discomfort Anxiety (DA) I was experiencing and had better stop making it worse by musting that it go away and awfulizing about how bad it felt. “I refuse to demand that these feelings go away (addressed the musting)” I said aloud over and over. “I can deal with these feelings whether I want to or not because I am not going to die (addressed the awfulizing).” I didn’t feel like it, but I stood up in my living room and loudly yelled these disputing beliefs while shaking my fists to emphasize my determination (Rigorous, dramatic disputation of false beliefs help incorporate more rational ones). Gradually, as I gave less and less into the “awfulness” of the moment by audibly reinforcing the disputing beliefs, I started feeling better.
Please understand, this panic attack left me feeling physically weak and fragile for at least a couple hours after the initial impact. I don’t want to sound as if my REBT training kicked into gear and all of a sudden the panic was gone. I also don’t want to minimize the absolute terror a person experiencing panic often feels. However, I am convinced that refusing to demand that these feelings go away, and not awfulizing how bad they were, as soon as I was cognitively able, were the first steps in the road to recovery.
After my panic attack, I had some time to think about how I might prevent additional attacks. I knew another panic attack would be on the way unless I had a plan for defusing it. REBT strategies for panic are far more effective if practiced before the ‘heat of the moment’. Using REBT, I knew I had addressed the Discomfort Anxiety (DA), but I had not addressed the Ego Anxiety (EA) that was probably at the heart of, and the impetus for, my panic attack. As I began to look at some of my core beliefs using the ones Ellis suggests as the beliefs behind most problematic emotions and behaviors, I realized that I had been unconsciously making some demands of myself for many months, perhaps years, that had culminated into these feelings of panic. I had also been awfulizing myself through self-downing for not meeting these demands in the way I thought I must.
Just a couple of years prior to this panic attack, I had lost a successful business due to several freak events. After losing my business and over the following months, I had begun to not only awfulize the loss of my business, but also myself (often called ‘self-downing’) for not being the success I thought I MUST be. Now, in a new town with a low paying job, I had bought into the belief that: “my life must not be the way it is; that it must be better with higher pay and greater status, and that I must not be the loser I was ultimately turning out to be” so I thought. These were all irrational or false beliefs creating my Ego Anxiety culminating in a panic.
My next step in recovery was to dispute these false beliefs pertaining to my worth by defining what gives me, or anyone else for that matter, true worth. REBT provides much insight into the area of self-worth and self-esteem and how it is derived. REBT focuses on the issue of self-esteem because it is a crucial issue in treating so many emotional problems.
REBT teaches individuals to recognize their great intrinsic worth regardless of their appearance, achievements, status, or the amount of approval they get from others. The difficulty is that our society tells us almost the opposite: a person’s worth is highly dependent on how attractive they are, their achievements, their status, and the amount of approval they gain from others. This philosophy has its utility as long as it is kept in balance and consists of preferential beliefs. One may eventually become very anxious and depressed if these beliefs become absolute demands that go unmet. People who tend to be perfectionists at all cost usually have many “absolutistic,” “demanding,” or “musting” type beliefs.
Without knowing it, I had attacked my worth by making success/achievement an absolute requirement through irrational beliefs such as: “I must not have lost the business I lost and I am a true loser for having lost it” and “Look at me now, I am a total loser for not having the status I once had and will probably never have again, I must have that status now!” As I backed off these perfectionistic type demands: “I must always succeed and have others think well of me” my Ego Anxiety diminished. I changed these dogmatic demands into preferences like: “I would really like to have a successful business again with the security it brings, but I can’t demand it and it would hardly make me a more valuable person by having it.” “I cannot accurately rate my value based on a few subjective things; I will think well of myself regardless of my performances in these areas while continuing to do the best I can to succeed at my goals.”
The irrational beliefs mentioned above having to do with Discomfort Anxiety and Ego Anxiety raised their heads many times after my first panic attack. And in reality, the Ego Anxiety beliefs originated long before losing my business. But the event of losing my business intensified them, gave them more steam and were finally manifested in my emotions and behavior in the form of a panic attack. My ‘panicky’ beliefs resulted in panicked behavior. I still have to deal with these beliefs from time to time, but I am able to dispute them using the REBT approach.
I had one other panic attack a few days after the first one described above, but it was much less intense and was shorter in duration. I have not had another one since that time. I attribute it to the techniques of REBT that keep my ‘musting’ and ‘awfulizing’ in check.
I understand that panic attacks are complicated and may have many casual factors. Some medical conditions, mitral valve prolapse for instance, are correlated with panic attacks. And, many people seem to be far more genetically predisposed to panic and anxiety than others. Certainly, exposure to certain life circumstances seem to play a role. Regardless of the causal factors, however, REBT may provide a very powerful approach for treating panic attacks in many clients.
In my opinion, REBT is an effective tool for helping many clients overcome all kinds of anxiety disorders. As a therapist using REBT, I would like to make some suggestions as to the process you follow when identifying the crucial issues involved with your clients’ panic or other anxiety issues:
- Address the Discomfort Anxiety. The best way to combat the discomfort (Discomfort Anxiety) of the actual panic attack is to refuse to make demands that the discomfort not exist (demandingness). Also, teach your clients to not awfulize about how bad the panic attack will be. This is almost impossible to do in the middle of a panic attack, but you can encourage your clients to practice not living in fear of them, or being hyper-vigilant about anticipating them. Trying to control the attacks will only make them more likely to occur. Also, panic attacks gain much of their power from the ‘awfulizing’ one does before and during the onset of a symptom: “Oh no, here it comes, I’m starting to breath faster, this is going to be the worst feeling in the world, I won’t be able to bear it, others will think I am completely crazy…” Disputing belief: “I don’t like these panic attacks, but I will get through it and it will not kill me. Just calm down. The less I stress about it, the less intense it will be over time. If I do have an attack, others will probably be concerned instead of think the worst of me.” Have the client practice relaxation and cognitive restructuring techniques long before the attacks occur. Teach your clients to not ‘fear the fear.’
- Address the Ego Anxiety. The client, and often the therapist, may not be able to easily identify the Ego Anxiety issue(s), but it is most likely at the heart of the panic attack. Therapists can usually aid the client in identifying the Ego Anxiety issue(s) by referring to the three basic core beliefs behind most emotional disturbance as identified by Ellis and mentioned in an earlier section (The three ‘musts’). Panic attacks usually start from the Ego Anxiety producing belief of “I must be perfectly competent in all that I do and because I am not, I am less than I must be”. Clients can often come up with many examples of how they are ‘musting’ and ‘awfulizing’ or damning themselves. In the above case illustration, I was able to identify a single event (loss of a business) contributing to my Ego Anxiety, but in reality, your clients may have many beliefs derived from many circumstances. Even if your clients cannot come up with specific situations, they will usually identify a general theme running through their beliefs like “I must always succeed” or “I can’t bear to think of someone disapproving of me”.
- Identify the core beliefs and help your clients practice disputing them. One of your main responsibilities as a therapist using REBT is to help your clients understand and identify what irrational core beliefs they will need to dispute. Learn what core beliefs are at the heart of panic attacks and anxiety in general. When discovering a client’s irrational beliefs, I start by asking myself “in what ways is this person ‘musting’ and ‘awfulizing’?” Using the example from the case illustration, there were several core beliefs that I needed to dispute. Some of them were: “I must not have lost my business” “I must not be a failure” “I have failed and therefore I am a failure.” Some of these beliefs originated not just from losing my business, but were issues in my family of origin as well. You will find that many of your clients can identify family of origin beliefs contributing to their panic. For example, a child whose parents demand perfection at all costs will likely see failure as “awful” instead of very frustrating. In addition to the beliefs identified above, clients who have panic attacks often worry about having one in the future and where it will happen. The belief is something like “I absolutely must not have an attack and if someone were to see me losing control it would be awful”. This belief needs to be confronted as well as the others. You can probably think of other beliefs at the heart of panic attacks that will need to be worked through with your clients. The keys to disputing false beliefs is to do it with force and on a regular basis. Examine the section on techniques for other suggestions.
Ellis postulates that people most prone to phobias may be generally stronger physiological reactors. He feels that this subtype is particularly resistant to facing their anxieties. For this reason, he feels, exposure therapies such as those originated by Wolpe, may be especially helpful to this population because of he structured but gradual exposure to the feared stimulus or situation. (Ellis, 1990) He includes REBT as an appropriate treatment for phobias, but acknowledges this subtype as been less likely to benefit from REBT alone.
Ellis applied REBT to depression, and found that depressed patients tended to have patterns of dysfunctional beliefs that were unique to depression, but very much in keeping with the general pattern of dysfunctional beliefs elucidated in REBT. He focuses on perfectionistic self-assessment, intolerance of others being inconsiderate toward oneself, and intolerance of challenge or frustration. Ellis points out that these individuals create a paradox of self-denigration and self-deification in that their harsh self-assessment contrasts with their demands that the outside world behave in the opposite manner, being considerate toward them. (ibid)
Ellis describes the three core beliefs that people tend to have “about themselves and the universe:” (ibid)
(I) "I must succeed at the important things that I do in life and win the approval of significant people in my life, and it is awful when I don't. I am therefore not as good as I should be, and am worth less as a person." (2) "Others must treat me kindly, fairly, and considerately, and it is horrible and they are louses when they don't." (3) "Life conditions must be easy, or at least not too difficult, and I must get all the things I want quickly and without too much of a hassle; and it is terrible when they aren't that way. The world is a really rotten place and should not be the way it is." (ibid)
Ellis stated that the first and third of these ideas were particularly likely in depression and pointed to research pertaining to self-rating of success by depressed persons as reinforcing this conceptualization. He points out that there is “implicit grandiosity” in these beliefs, which he refers to as “omnipotent insistences.” (ibid) Although grandiosity is not as obvious in the third belief, it exists in the sense that the individual with this belief is putting oneself above the normal frustrations of life through such a demand upon the world. The grandiosity is much more obvious when framed as, “world conditions must be easy and immediately gratifying for me,” or “I am (or should be) a great person for whom everything goes easily and well in life…” (ibid)
Ellis found that some depressed patients did not improve adequately with REBT that focused on this kind of ego anxiety. He found that, even when ego anxiety was addressed, discomfort anxiety was a powerful trigger to revivify ego anxiety. Anxiety, though more situational, is readily interpreted in an egocentric way by these less responsive patients. Ellis’ work with these patients became more effective when he concentrated on the discomfort anxiety, once ego anxiety was improved. (ibid)
Ellis speculated that depression is increased by the additional burden of processing irrational thoughts associated with depression. (Eysenck, 1992)
REBT Therapy Methods
Theory as Method
You could say that one of the most important methods of REBT is its very explanation of human behavior and emotional problems. This is because patients are led to understand and utilize the REBT perspectives. This is perceived to be a key aspect to taking responsibility in a constructive manner.
An important dynamic that occurs as patients come to understand the REBT perspective is the patient’s improved ability to have some objective distance from habitual ways of thinking and reacting. A valuable aspect of this distance is that the patient is in a better position to cultivate a more effective reaction or thought pattern.
Key Initial Steps in Applying REBT
Once a clinician has determined that the patient has a problem that is likely to be amenable to REBT, the clinician makes an initial estimation as to the type of beliefs that are fueling the problem. For example, Ellis discusses a hypothetical patient who is afraid of not only snakes, but pictures of snakes. If the patient is capable of understanding that the picture won’t bite, then the patient can start there.
His first goal is to help the patient stop “awfulizing” the anxiety itself. In other words, the goal is to help the patient see that the anxiety is not directly threatening. Whatever anxiety is associated with the situation, the bulk of the anxiety is a reaction to the initial anxiety.
Thus, the client is helped to see their reaction to anxiety an unnecessary bother. Once the client adopts this perspective, they become willing to directly confront the thoughts that amplify anxiety.
REBT makes no bones about being philosophically based. Ellis (1994) expresses an important philosophical element of REBT in discussing the REBT approach to patients, saying, “The REBT practitioner is able to give clients unconditional rather than conditional positive regard because the REBT philosophy holds that no humans are to be damned for anything, no matter how execrable their acts may be. Because of the therapist's unconditional acceptance of them as a human, and actively teaching clients how to fully accept themselves, clients are able to express their feelings more openly and to stop rating themselves even when they acknowledge the inefficiency or immorality of some of their acts.”
REBT helps patients stop “rating” themselves in a manner that makes their emotions and functioning vulnerable to global and disabling negative self assessment, particularly when it is habitual. The philosophy expressed above, and the stance taken by REBT therapists, is in line with that objective.
This work culminates in the patient’s understanding that their emotions and behaviors spring from core beliefs that can be articulated and addressed.
From this point, the articulation of the most disabling of the core beliefs takes place. The client is then able to work with the therapist in disputing these beliefs and adopting effective beliefs. These objectives are discussed in greater practical and theoretical detail below.
Acquiring the ability to articulate beliefs that were previously unconscious yet powerful mechanisms of suffering and deprivation is a powerful, liberating experience in itself, yet this is just the beginning. The tools of REBT and their habitual use create hope and tremendous improvement in people’s lives.
The Approach to Self Esteem and Core Beliefs
In learning to improve self esteem, patients can alter thought patterns that had been unconscious or taken for granted. The REBT perspective on self-responsibility enhances this.
Unconscious and highly influential thought patterns are called “core beliefs” in REBT. These beliefs affect self esteem and the type of reactions people have to all situations in life.
REBT has a collection of methods that help people become aware of their thought patterns. This is necessary because many of these beliefs are not conscious.
One method, for example, is to help the patient put the meaning of their feelings and behavior into words. If a patient is unable to volunteer for assignments at work that would improve their reputation, and the patient feels very bad about any sense of shortcomings or failures, then a few questions from the therapist may elicit core beliefs.
In response to questions such as “What does that mistake of yours mean about you?” or “What do you think people may believe about someone who does that?” may yield a belief such as, “I must be perfect, or I am a worthless failure and will be scorned by others.”
Once put into words, such a belief is easy to recognize as destructive. As in this example, the patient can readily see that there are only two possibilities, perfection and worthlessness. Since humans are inherently fallible and will inevitably make mistakes, this core belief cannot stand the light of day.
Once the patient has a more objective perspective on such a belief, the therapist can guide them to see how pervasively it affects their life, and how much it has prevented them from having desired outcomes such as improved income or better social relationships. Patient motivation to change such beliefs is greatly improved with such awareness.
Core Beliefs as Rules
Ellis frames core beliefs as rules as a means to help people see their thoughts as part of a self-limiting and rigid pattern of reacting. When one looks at a “rule” that one has been applying in life, it becomes easier to see that the rule is not always relevant, and can even be destructive. Some of these rules are so disruptive that they need to be changed completely.
A good example can be found in perfectionistic beliefs, as described earlier.
The discussion of core beliefs must include a look at the emotions involved. Ellis makes the connection by saying the people with dysfunctional beliefs fueling neurosis have elevated their desires to the level of need. Thus, the frustration of these “needs” becomes highly arousing and threatening. Ellis refers to the conversion of hopes into musts as “musterbatory thinking”. (Ellis, 1990)
Decrements in sense of self efficacy can arouse anxiety not only through harsh self judgement, but also through the sense of vulnerability and loss of control associated with the beliefs that one is incompetent and has no social capital. From that perspective, the person will not be effective in preventing bad outcomes and will be discarded by society; their lives will be terrible.
Additional Exacerbating Factors
Ellis believes that frustrating circumstances such as poverty are most harmful when interpreted through the dysfunctional rules addressed by REBT. While frustration is escalated to severe emotional reactions, its significance as a source of self-deprecation creates even more emotional disturbance, resulting in a kind of emotional feedback loop that can be highly destabilizing.
Ellis also conjectures that populations most prone to poverty may be more likely to suffer from genetic traits that increase vulnerability discomfort anxiety, and thus to emotional destabilization.
Research has shown that depression and anxiety can cause sustained processing deficits, even when normals are subjected to these states. (Eyesenck 1992) This can contribute to the snowballing effect of the anxiety and irrational beliefs, by making it more difficult to identify, critique, and rehabilitate irrational beliefs, as well as helping to produce the need for a competent therapist to facilitate this process.
Learned helplessness, a term for the unassertive or depressed behavior that results when a person or animal cannot control or influence a repeated negative outcome, was originated by Seligman. Seligman and other reformulated the model, incorporating beliefs. In this model, persons who tend to attribute their successes to external factors, and their failures to innate flaws, are particularly prone to learned helplessness and depression. People especially prone to learned helplessness tend to have family backgrounds in which they were not well-accepted as they were, had parents who set high standards for them, and yet who did not see them as being as capable as other children.
Ellis (1993) defines neurotic behavior as “stupid behavior by a non-stupid person.” In part, this is intended to convey that the neurotic behavior or thinking is persistent and reinforced without the insight and corrective action that the person is fully capable of. This persistence of dysfunctional beliefs and behavior is called “drifting” or “goofing”.
Continuing REBT Treatment
Once the patient has gained a more objective understanding of how their dysfunctional beliefs are affecting their lives, clients are aided in modifying those beliefs. The reduction in dysfunctional beliefs, and habituation of functional ones, greatly increases the patient’s ability to tolerate stress, frustration, and assaults on their self-esteem.
Ellis emphasizes the importance of distinguishing between discomfort anxiety and ego anxiety, saying that confusing the two can stymie treatment. The therapist may shuttle between the two, or treat them as a single entity.
Ellis (1990) provides the example of a single dysfunctional premise that plays out into two different anxieties, that, "I must get good results at the things I do, especially in producing adaptive feelings.”
Once associated, belief expresses discomfort anxiety: "When I do the wrong things and produce the wrong kind of feelings, I can't stand the discomfort I create; the world is just too hard for me and I might as well be dead!". It also produces an ego anxious expression: "When I do the wrong things or have the wrong kinds of feelings, I can't stand myself for acting so foolishly; I am hopelessly inept, will always fail to get what I want, and don't deserve to live!"
Ellis states that these must be treated separately, and that the discomfort anxiety is likely to be the most challenging of the two to treat.
Ellis feels that the drive to escape anxiety is so strong, that many people are drawn to dramatic and eccentric belief systems when those systems promise such an escape. If components of the system work, then the person may adhere to the entire belief system, even though only a specific aspect improved their anxiety. In this vein, Ellis cites fundamentalist religious beliefs that include being protected from harm through supernatural means. He offers a similar perspective regarding faddish approaches to psychotherapy and self help such as primal scream, a cathartic therapy.
Phases of REBT Treatment
At first glance, the phases of REBT treatment may look generic to therapy, however, this section points out important elements that can be tremendously helpful in completing these phases effectively, and that are specific to REBT practice. Elements that are more generic to psychotherapy will not be discussed.
The first phase is to engage the client. In keeping with the philosophy of REBT, the therapist is respectful, warm, and empathic.
The second phase is to assess the patient, the problem, and the situation. Starting with the client’s view helps the therapist begin to understand the levels of thinking, such as the patient’s attributions, discussed earlier.
The therapist assesses for secondary disturbances that may interfere with therapy. The client with ego anxiety may be highly self-critical for needing therapy in the first place. This self-critical attitude may be compounding an already depressing and self-defeating set of core beliefs.
Third, prepare the patient for therapy. The collaborative nature of REBT is aided by clarifying the treatment goals with the patient. In order to ensure that the patient can understand and act on the goals, and can gain motivation by seeing them realized, the goals should be concrete and specific. The goals must be agreeable to the patient.
Educate the patient about REBT in ways that enhance understanding and motivation. A scientific or detailed understanding is not important. Compelling metaphors and language are far more important in supporting motivation and progress in treatment. Include the kinds of approaches REBT uses.
Phase three is to implement the treatment program. The bulk of treatment occurs here. The activities of this phase are discussed below. Much of the activity lies in analyzing incidences of symptomatic feelings and behavior.
It is a profound experience for patients to begin seeing more and more of the painful situations in their lives turning into opportunities for happy, creative, successful living. Each new uninspected situation yields an ah-ha experience, creating a sense of expansion and illumination that is highly reinforcing in increasing the patient’s motivation.
The fourth phase is to evaluate progress. This actually occurs throughout treatment, but when nearing termination, this evaluation helps to establish the appropriateness of preparing to terminate treatment.
The fifth and final phase is that of termination. The client is prepared for termination when the goals of treatment are achieved. However, it is important to include the ability to tolerate and effectively handle setbacks and new challenges in life. This includes a recognition that returning to treatment is not evidence of being fatally flawed and undeserving, or some other self-judgment that could prevent the client from using therapy if it is needed in the future.
Activities in REBT
REBT philosophy emphasizes working vigorously and consistently to achieve philosophical change. Thus, various specific activities are prescribed for during and outside of REBT sessions. Each activity can be seen to reflect specific effective ingredients of REBT.
Ellis has referred to other treatment approaches as sometimes, if inadvertently, using effective ingredients of REBT to help patients. For example, he conjectures that, “Freudian and primal therapists may unwittingly help them see that feelings of anxiety and anger are not unbearable and may thereby help them to overcome some of their discomfort anxiety.” (Ellis, 1990) In the same paper, he expressed the idea that phobia treatments such as Wolpe’s systematic desensitization could be better understood when viewed though the lens of discomfort anxiety. For example, he felt that slower methods would be less likely to help people with DA because of their high level of resistance to exposure to the anxiety-provoking stimulus. (ibid) On the other hand, he felt that the superior results of in vivo exposure over cognitive restructuring for some patients was due to the need for highly autonomically activated patients to reduce this level of arousal before they can respond to cognitive methods. (ibid)
ABC’s of REBT
REBT exposes participants to various ideas in positive, accessible terms. One of the best-known of these are the ABC’s of emotional disturbance. The ABC’s stand for the Activating events, Beliefs about the events, and Consequences that result.
The ABC’s form an understandable structure for analyzing situations from the REBT perspective.
The following is an example of an analysis and plan using the ABC’s (Yourell, 2005):
A. Activating Event
The event: A friend didn't acknowledge the funny video link I sent yesterday.
My inferences about this event: He's washed his hands of me because I'm an idiot for assuming he'd think it was funny. He's too sophisticated for me. I only get low-rent friends. They're useless. I'm going to die cold and alone.
B. Beliefs (How I evaluated the Activating Event)
1. I can't face such a horrible fate.
2. I'm so deeply flawed that I'm beyond hope.
3. To feel acceptable to society, I must always receive immediate, positive feedback that my ways of reaching out to people are pleasing, entertaining and funny. (Core Belief)
C. Consequences/Consequential feelings (my reactions)
Feelings: Hopeless, depressed.
Behavior: Withdrawn, pensive, fatigued, unclear, distracted, overeating.
D. Disputing beliefs (New, rational beliefs for a constructive reaction)
1. Gaffes like this happen without people suffering total social annihilation.
2. This may not even be a gaffe, he could be on vacation or something.
3. If he does reject me, it isn't the end of the world. There's, what, a gizillion people in the world?
4. I love it when people think I've done something cool, but treating it like my life is hanging in the balance is not exactly objective. In fact, it messes with my emotions and ability to concentrate at work. I'll be better off seeing such things as preferences instead of matters of immediate survival.
E. New Effect (how I would prefer to feel/behave)
Creative, inquisitive, interested in developing better social graces, online or otherwise.
F. Further Action (What I’ll do to avoid repeating the same irrational thoughts and reactions)
1. Call my friend about something more appropriate like a social event where he won't be on the spot if he doesn't want to go.
2. If he doesn't show interest, I'll keep developing my other friendships and ways of making more sophisticated friends.
3. I'll review the homework from my therapist.
4. I'll even do the homework. I'll do something each day that moves my social life forward. I'll treat it like a really desirable challenge instead of an ordeal, by talking to myself that way.
Disputation, according to Ellis, lies at the heart of REBT. Disputation refers to teaching participants to, “recognize and dispute their irrational self-statements, as well as persuading them to do so vigorously and often…” (Ellis, Bernard, 2006) In an effective practitioner, this is elevated to an art form, because it is generally futile to simply try to argue people out of long-held, deep-seated, and not-very-conscious beliefs.
This is especially true with populations most in need of REBT, as their anxieties often include overreacting to experiences that they are prone to experience as intolerable criticism.
Perkins (2007) describes three main methods of disputation, which he refers to as putting the beliefs “on trial.” (Perkins, 2007) The methods can be used at each stage of an ABC analysis. They are empirical, logical and pragmatic disputing.
In empirical disputing, the absence of evidence for the belief helps the client reevaluate the belief. Evidence that supports beliefs that are more realistic can support change.
In logical disputing, the client is helped to see that the belief cannot be supported by logic, and that there are other, more logical, perspectives.
Pragmatic disputing asks the bottom line question of how and how much the belief is helping or harming the patient. This can be especially helpful in disputing self defeating beliefs.
Disputation as Homework and Self Help
Ellis (1994b) has recommended that people spend at least ten minutes a day disputing irrational beliefs (DIBS). The following is a structure for doing so, adapted from REBT materials and articles.
1. Identify a pattern of suffering in your life. The best patterns for this exercise are those that resemble the neurotic suffering that REBT treats.
2. Figure out what the underlying self-defeating core belief(s) are, and select one to work on. The list of the twelve most common self-defeating beliefs can help. Part of a good target belief includes a should, ought or must.
3. Ask if there is rational support for the belief. If the answer is really yes, then return to step two, and find a belief that more closely resembles the self-defeating beliefs.
4. List all the evidence that this belief is not factual.
5. Note any evidence of any truth of the belief.
6. Note what the worst thing is that could happen to you if your demand for getting your way is not met. (Getting what you feel you must get, or avoiding what you feel must not happen to you.)
7. Note what good things you could make happen of you don’t get your way, as in step six.
Ellis recommends the use of behavioral or self management methods in order to develop this into a consistent habit. For example, you could withhold a desirable activity or treat until the activity is complete, and then give yourself the reward. On days you fail to do the activity, you could provide an aversive experience, like having to get up half an hour earlier. (ibid)
Ellis (ibid) encourages vigorous recitation of your disputing new, functional philosophical beliefs. He says that anything less than a forceful, compelling tone leaves the door open to back sliding so that the prior self-defeating belief can regain power over your life.
He recommends using a recorder so that you can listen to your new beliefs and, consequently, make them into habitual patterns of thought. He even recommends doing the recording over, even more forcefully than before. He says that you can add to your commitment by playing it for trusted friends, your therapist, or for your therapy group. (ibid)
Preparation to cope with setbacks and new challenges effectively.
Patients are vulnerable to relapse or return of symptoms. There is a frank discussion of vulnerabilities. For example, a perfectionistic patient might feel that returning to therapy is a terrible failure, when, in fact, it is an opportunity to further increase their resistance to dysfunctional thought patterns.
Steps in a Typical REBT Session
The following steps exemplify how the material discussed above can be applied in a typical session of REBT. The emphasis in REBT is so much on the acquisition and deployment of functional core beliefs, that the sessions can be thought of as “training sessions.”
1. Homework Review: How effectively did the patient apply the assigned and agreed upon homework. Failure to carry out the homework can help identify obstacles to progress.
2. Target Problem: Determine what problem or symptomatic incident is most appropriate to work on in the session.
3. Perform an ABC analysis as discussed earlier. Be sure to include any secondary symptoms. These are the patient’s reactions to their reaction, so to speak. As discussed, this may take the form of negative, global self-judgment for having the anxiety or other reaction in the first place.
4. Enhance Client Understanding and Motivation: Help the client understand any aspects of the analysis that they are having difficulty with. Make sure that they understand how their thoughts are driving their subjective experience and their behavior. Highlight the destructive effects of the identified pattern. This can include emotional pain, personal deprivation, and the indignity of contributing to their family, workplace or other settings in a manner that is beneath their potential and that is not according to their higher values. Handled properly, this can be highly motivational.
5. Establish Target Responses and Core Beliefs: Determine with the client what would constitute constructive responses to the triggering circumstance. This can itself be a process of disputing beliefs, as the movement toward a healthier response can bring the client into conscious awareness of various iterations of the irrational core beliefs that are in play in the trigger situation. Include in the target responses how the client wishes to think, feel, and act. This can include creative brainstorming. Even inappropriate behaviors that come up as ideas may be utilized in treatment to generate a more open mind and good humor. Such ideas can spark feelings that the client finds desirable, and this in turn can lead to ideas that are more appropriate. For example, suggesting, tongue-in-cheek, that the client send a greeting card that says, “Thinking of you. In treatment for it,” led to the discussion of alternatives to being preoccupied with a difficult family member. Various methods for disputing beliefs are discussed earlier.
6. Based on the session and previous progress, establish a new homework assignment that is keyed to practicing the new constructive core beliefs developed in the session. Address any potential obstacles to completing the homework.
REBT can be done with a wide variety of methods when they are employed in service of the goals and objectives of REBT. The most commonly used techniques in REBT are cognitive. Below are typical examples of these cognitive techniques. They are drawn primarily from Froggat’s (2005) annotated list.
Dispute a Double Standard: Clients with dramatic reactions to their own imperfections may become more amenable to changing this practice when they realize that they would not apply such a judgment to others. The reverse of this will apply to those who are harsh in criticizing others.
Put Catastrophic Thinking Into Perspective: The client can create a scale where the “catastrophe” is rated between 0% and 100%, where 100% is the worst possible catastrophe. The therapist has the client add various conceivable catastrophes, such as being burned alive. As these are added, clients will typically reduce their rating of the catastrophe and become more open-minded about altering their reaction to the undesirable circumstance.
Devil’s Advocate: Tell the client that you will adopt their position, and that they are to practice talking you out of it. This can help the client perceive the irrationality of their position and begin to habituate and articulate effective thinking.
Reframing: Changing the frame of reference in the client’s perspective can create dramatic shifts in thinking. For example, highlighting the ways that an undesirable situation constitutes a challenge that serves as an opportunity for the client to practice effective coping strategies and express their higher values and creativity is a very potent reframe.
Imagery: There are endless ways to use imagery. Examples include time projection, in which the client imagines life after the uncomfortable situation, and realizes that life can go on much as it has. This can be enhanced by imagining the benefits of creative, effective improvements in coping, and the acquisition of useful resources.
REBT emphasizes action, and behavioral techniques are opportunities to take action.
Exposure: This is a common technique, in which clients expose themselves to situations that they have been avoiding. Depending on the type of anxiety involved, imaginal exposure and other cognitive methods may be necessary in order to gain the client’s consent to this method. The experience should be one that will help to alter the client’s tendency to awfulize or otherwise predict unrealistically extreme outcomes.
Shame Attacking: To reduce a client’s fear of shame, the client can engage in mildly shame-provoking behavior, such as being seen in public with messy hair, while confronting the unrealistic thoughts that this produces. This may be done along with the therapist.
Risk-Taking: Clients who begin taking action that they have unrealistic fears about can be a powerful way to confront such fears. An excellent example is that of developing the ability to tolerate failure by taking on challenges that the client has been avoiding. It could be a simple as developing conversational skills by approaching strangers in appropriate social settings.
Paradoxical Behavior: In a strategy reminiscent of wearing orthopedic shoes, the client can practice behaving in a manner that is the opposite of their typical dysfunctional reaction to a situation. A benefit of this approach is that it confronts the tendency to procrastinate until one feels like taking the prescribed action (which may never happen). It supports a sense of immediacy and dynamism in confronting dysfunctional behavior. It can also build a sense of inner power and freedom.
Postponing Gratification: The proneness to hedonism that Ellis urged people to overcome is directly attacked in this strategy. The client builds the capacity to postpone gratification and make room in their life for more of the constructive behavior that they need by putting off various automatic behaviors such as eating sweets or blurting out a manipulative or judgmental statement. Where behaviors that are harmful to the client’s mental health and emotional stability are concerned, the obvious additional benefit is that the client may become more capable of doing homework and participating in treatment sessions as a result of increased mental clarity and emotional resilience.
REBT with Children
Ellis has referred to REBT with children as teaching them, “to talk more sensibly to themselves.” (Bernard, Ellis, Terjesen, 2006) He states that Adler, early in the twentieth century, was among the first to take a direct psychological approach to working with children, and to bring this into the schools.
To emphasize the importance of this work, Ellis points out that children are exposed to increasing challenges in a globally connected and media-rich world and in communities with increasingly serious social problems. At the same time, most children and even many adolescents are at a concrete state of intellectual development that makes them vulnerable to irrational patterns of thought that, under stress, can lead to destructive thought patterns and acting out. (Vernon, Bernard, 2006)
Ellis did a great deal to support the use of cognitive restructuring approaches in schools, even starting a school specializing in this approach in New York, known as The Living School, in 1970. He later converted it into a program to teach these methods, the Rational-Emotive Education Consultation Service.
By the 1960’s, Ellis states, REBT was widely embraced by behavior therapists in the schools in the U.S. to deal with behavioral, emotional, and achievement problems in young people.
REBT has generated much interest, numerous supportive research outcomes, and many publications ranging from books for counselors to materials to use in schools with children.
The approach is also applied to help parents, teachers and caretakers of children, either for the direct benefit of the children, or for the caretakers themselves. In this regard, REBT emphasizes that the very attitudes and behaviors that REBT treats in adults can have a harmful effect on the self-esteem and performance of children.
Ellis calls a healthier approach to child raising and teaching as being “firm and kind” and “authoritative” rather than authoritarian. (Joyce, 2006) In service of this approach, Ellis advocates for a consultive relationship, in which the practitioner and caretakers or systems work collaboratively in a problem-solving frame of mind.
REBT practitioners emphasize that depression in young persons is a serious problem that must not be written of as part of the dramatic and emotional experience of adolescence. It can be distinguished from normal adolescent emotionality by signs such as loss of interest in normal activities. Intervention should be prompt, given that adolescent depression can be volatile and escalate quickly to destructive acts.
Although REBT, as a practice, emphasizes cognitive work, it is also cognizant of the non-cognitive factors that contribute to depression and often need to be addressed. These include neurobiological and genetic factors.
Ellis points out that anxiety, which is emphasized in REBT theory, has been shown to have a great deal to do with the initiation and exacerbation of depression.
Ellis writes that aggression in children, particularly predatory aggression, must be promptly treated behaviorally and through appropriate external structure. While he states that REBT is less effective with this population, it does have an important use in helping to modify caretaker behavior in service of effective treatment and management of such children. (ibid) He also finds that it contributes directly to working with children in an appropriately developed program of treatment and management.
Successful group therapy using REBT with children dates back to 1959, according to Ellis. Ellis feels that, with children, group therapy is more effective than individual therapy. REBT takes advantage of beneficial dynamics of group therapy. One such dynamic, and a powerful one, is that of “universality”. This is the recognition by group members that they share common challenges. The resulting decrease in feelings of isolation and powerlessness are very much in line with the REBT goal of reducing the spiral of anxiety that leads to depression, underachievement, and destructive acting out.
Because of the value of honest and constructive feedback by peers in group settings, REBT groups have included peer review and work on homework assignments. This approach blends mild competition with supportive work, and is very constructive and motivational. Also, peers can be at times more effective at recognizing dishonesty than the therapist.
Group work can reinforce the power of REBT in confronting dysfunctional beliefs such as those that interfere with performance, by providing the confrontation in the form of logical, constructive input from multiple peers. Peers have been shown to have a profound effect upon the later adult personality that rivals or exceeds that of parents when genetic influences are controlled for.
The considerations that are generic to group work and work with children apply in REBT groups as much as they do in other group work and will not be addressed here.
REBT with Couples
REBT looks for dysfunctional feedback loops in the individual, but also in relationships. In a presentation, Ellis (1993) describes how a husband’s intolerance of his wife’s inadequacy and dependence reinforced those traits, worsening the problem.
He feels that marriage is already challenging, so that “disturbed people” have an especially difficult time adjusting to marriage. People tend to enter marriage with unrealistic expectations, and people who hold the kinds of dysfunctional beliefs that REBT treats have an especially difficult time tolerating the violation of those expectations.
The volatility of their negative reactions can easily eclipse and eventually destroy the positive aspects of the relationship and of their partner. Add to this any periods of increased pressure or stress, and neurotic traits may become amplified. Should the partners tend to have low expectations of each other, yet have perfectionistic expectations, as is typical of those bearing dysfunctional beliefs, then all the troublesome dynamics whether typical of a relationship or, worse, part of a difficult relationship, are amplified further.
In treating couples, Ellis may isolate a specific behavior, such as blaming, that is impairing the relationship, and then unearth the “assumptions that create and perpetuate the hostile feelings.” (Ellis, 1993) This highlights the directness of REBT, and fidelity of its theory with practice.
In addition to confronting neurotic assumptions, the patient’s work in REBT includes sincerely struggling with the question of how the patient can be different, that is, more effective, instead of maintaining a self-defeating focus on how their partner is imperfect.
Continued Evolution of REBT
Increasing Knowledge on When to Apply REBT
In addition to the more obvious applications, CBT approaches such as REBT can be applied in situations in which psychodynamics are not an obvious cause of emotional imbalance. There may be any number of subtle or not so subtle dysfunctional thought patterns posing obstacles to fully embracing a treatment plan for a medical or psychiatric disorder that is not being directly treated with REBT.
For example, persons with schizophrenia tend to have great difficulty accepting the nature of their diagnosis and the value of medication. Those who do are vulnerable to depression. REBT methods have been employed to assist patients in complying with treatment recommendations and leading happier lives.
REBT has more direct and immediate success with emotional and behavioral problems that originate less in biological disorders or truly threatening situations. People are less likely to have irrational beliefs fueling a fear of heights (a relatively threatening situation) than they are of social situations that are not inherently physically threatening. (Sutton-Simon, 1979)
Additionally, Ellis pointed out that Sutton-Simon theorized that while discomfort anxiety may tend to arise more directly from specific situations, ego anxiety may be more generalized because it pertains more to the person, with less dependence on context. (Ellis, 1990).
Opportunities for Integration and Expansion
Biology of Mental Disorders
Given the effectiveness of REBT with many populations, and given its adjunctive value with disorders that are now conceived as having a more biological than neurotic basis, the developing biological understanding of mental disorders does not so much undermine REBT as put it into perspective. It will probably lead to modifications of CBT for many disorders, as well as support the use of alternate methods for some disorders.
While REBT claims to embrace a biopsychosocial model, it does not have the ability to cure biological problems, and its theory of the causality of mental disorders that it treats is almost exclusively from thought to disorder. It does not incorporate a neurobiological vulnerability model of illness. However, a modern understanding of the biology of depression and other disorders is undermining the fundamental assumption of REBT where many disorders are concerned, including those that it treats.
For example, depression has been shown to cause or increase irrational thinking and even lead to psychosis. Medication can improve thought patterns of depressed people who did not experience CBT.
The anxiety, depression, avoidance and other symptoms of PTSD resemble problems that REBT would treat. Thought patterns resembling irrational core beliefs correlate with vulnerability to PTSD. CBT has been shown to be of benefit in PTSD. However, the integration of somatic approaches (EMDR, psychopharmacology) in PTSD treatment, and the fact that biologically-based mental illnesses predispose people to PTSD, suggest that REBT is not a cure for PTSD, but can be an important component of treatment. CBT is an important aspect of EMDR causing it to be called a somatic and a cognitive behavioral therapy.
Comorbidity clusters point to genotypes and other biological factors in vulnerability to depression and anxiety. (Solvason, Ernst & Roth, 2003) The existence of mental disorders in animals that resemble conditions treated by REBT suggests that thought patterns are not a prerequisite for these conditions. Learned helplessness was first observed in animals.
At one time, Ellis (1993) stated that psychosis is among the “emotional disorders” and is “caused by crooked thinking.” Even at the time this statement was published, this was not a claim that was accepted in either the clinical or scientific communities.
Also, a search on PubMed shows little application of REBT in psychotic disorders. Nonetheless, CBT applications to largely biological disorders have shown promise in various applications, in conjunction with biological and other approaches.
An important example is that of cognitive work with obsessive compulsive disorder that actually uses the medical understanding of the disorder to help clients become motivated to confront dysfunctional thoughts and behavior that are symptomatic of the disorder.
Genetics and Neurobiology
Genetics is revealing that some groups of people are more vulnerable to stress than others. These groupings are referred to as subtypes, and the genetic differences are called polymorphisms. In time, it is likely that genetic subtypes will be identified that are more or less likely to benefit from specific psychotherapeutic protocols. This kind of research undermines the idea that thought patterns directly cause emotional disorders.
Ellis proposed that there are subtypes with high and low physiological reactivity. Genetics and other sources of neurobiological knowledge are helping to explain and further develop these subtypes. This kind of exploration may help to develop CBT or alternate approaches for the conditions that are less responsive to CBT.
Genetic and neurobiological research is causing biological causal factors to loom large in understanding mental and emotional disorders, while the theory of REBT is coming to appear to be more of a clinical tool than a valid theory.
An excellent example of a long-held and intuitive belief now threatened by biological knowledge is the idea that violence in adults is caused by childhood exposure to psychological trauma and violence. Instead, genetic research supports the idea that violent adults are more likely to have a violent or psychologically traumatic childhood because of the genes they share with their parents.
Clinicians steeped primarily in intrapsychic theories of disorders are more likely to have difficulty utilizing and adapting to such understandings.
REBT may achieve some of its gains through increased stress resistance that plays out in both psychological and biological ways. Stress can induce depression. Neurobiological factors being considered in increasing stress resistance include “serotonin, the 5-HT1A receptor, polymorphisms of the 5-HT transporter gene, norepinephrine, alpha-2 adrenergic receptors, neuropeptide Y, polymorphisms of the alpha-2 adrenergic gene, dopamine, corticotropin-releasing hormone (CRH), dehydroepiandrosterone (DHEA), cortisol, and CRH receptors. These factors are described in the context of brain regions believed to be involved in stress, depression, and resilience to stress.” (Southwick, Vythilingam & Charney, 2005)
With more detailed knowledge of the specific psychosocial factors that increase stress resistance and reduce vulnerability to depression, REBT and CBT in general may be enhanced by more specifically and relevantly targeting these known variables. REBT is already applied with an eye to enhancing the individual’s capacity to acquire and utilize psychosocial factors that further promote emotional stability and rational beliefs already being targeted in REBT.
“Psychosocial factors associated with depression and/or stress resilience include positive emotions and optimism, humor, cognitive flexibility, cognitive explanatory style and reappraisal, acceptance, religion/spirituality, altruism, social support, role models, coping style, exercise, capacity to recover from negative events, and stress inoculation.” (Southwick, Vythilingam & Charney, 2005)
Cognitive Profiles and Deficits
As greater understanding develops as to how various learning styles, cognitive deficits and other cognitive profile factors affect the response to psychotherapy and related interventions, refinements can be developed that address these factors. For example, perpetrators of domestic violence have an elevated incidence of cognitive deficits that pose a challenge to therapists that expect a more typical response to treatment. By consistently psychologizing the apparently resistant behavior, a therapist may be providing irrelevant or misguided treatment to such a population.
Introjection of Culture-Based Stigma
With a focus on individuals, REBT has not paid much attention to cultural factors that affect beliefs. Stigma is of great importance, because it is such a powerful influence on behavior. The precipitous increase in eating disorders among women in Fiji after the introduction of television is a striking example. (Becker, Burwell, Herzog, Hamburg & Gilman, 2002) Directly and consciously addressing the impact of culture and stigma can assist patients in gaining the objectivity that REBT holds as a key step of effective therapy.
Secure Base Priming
Attachment theory and subsequent research support the idea that significant improvements or undesirable change can occur as a result of messages that effect the “secure base” of attachment-related thoughts. People “primed” with a secure base appear to be more open-minded, less hostile, and more capable of activities that resemble REBT. (Mikulincer, Hirschberger, Nachmias, Gillath, 2001) (Mikulincer & Shaver, 2001) The emphasis of REBT upon a nonjudgmental and supportive approach may improve the effectiveness of REBT from the theoretical perspective of attachment theory through secure base priming. The development of rational core beliefs may be enhanced with content that generates secure base priming.
Neuroplasticity and the Rehearsal of Dysfunctional Beliefs
Emotional cathexis reinforces learning, and repetition helps establish habitual ways of thinking. Emotional arousal is generated by the anxieties Ellis postulates. Emotional arousal creates energy that a person must somehow cope with. This arousal tends to activate thinking that attempts to create meaning and to gain greater control. For people who have a tendency to hold dysfunctional beliefs in the first place, these dynamics may lead to highly charged and thoroughly habituated dysfunctional beliefs. This may help explain why people with the anxieties described in REBT theory do not independently eliminate them, and instead require psychotherapy that addresses dysfunctional thought patterns.
Neurobiological knowledge is likely to lead to further refinements in CBT.
Paradox and Motivational Interviewing
The indirect manner that paradoxical techniques and motivational interviewing approaches have in assisting individuals in altering dysfunctional beliefs, and in enhancing their motivation for change have influenced CBT.
The understanding of behavior from the perspective of behaviorism has led to methods that do not rely on rational thought to alter behaviors and attitudes, but rather, on reinforcing and aversive stimuli. This can be integrated into talk therapy in subtle and not-so-subtle ways. A subtle way might be making the expression of dysfunctional thought more effortful, while the expression of functional ones is made into a more enjoyable experience. This is a way of utilizing the “short-range hedonism” that was of concern to Ellis. The power of change at a more primitive level of the brain is evidenced in the ability of behaviorists to train animals to perform complicated stunts.
Somatic Psychology and Reprocessing
Our understanding of the role of REM sleep and somatic psychotherapy methods in leading to the reprocessing of memories, and the acceleration of cognitive therapy are influencing the course of development of CBT.
The Challenge of Improving Frustration Tolerance
Ellis stated that he does “not find it easy to help people raise their level of frustration tolerance and thereby reduce or eliminate their discomfort anxiety.” (Ellis, 1990) He attributes this to the human biological propensity to being “short-range hedonists…” (Ellis, 1990)
The search for effective methods is important. Dialectical Behavior Therapy is a relevant development, in that it assists persons with borderline personality disorder, a highly emotionally destabilizing condition that is associated with impulsive behavior and drug abuse. The approach emphasizes psychoeducation and structure in a group setting, and, especially in the beginning, does not use participant interaction that is typical of psychotherapy groups.
REBT emphasizes the problems of individuals reacting to situations. However, increasing attention in the mental health field is being paid to matters of poverty, domestic violence, the direct effects of addiction, and other psychosocial factors. As REBT practitioners and theorists attempt to expand the relevance of REBT to additional populations, substantial challenges exist, including limited funding for mental health in schools and in community settings.
Schizophrenia and other Psychotic Disorders
In the U.S., the application of CBT of any kind to psychotic disorders lags in contrast to other developed nations. This has been attributed to the dominance of medication-oriented treatment for psychoses and to the absence of universal health coverage in the U.S. (Turkington, Kingdon, Weiden, 2006) Research on CBT with schizophrenia is very limited, but there are promising studies contrasting it with various controls. (ibid) CBT has the strongest supportive research as a psychotherapy modality for schizophrenia. (Dickerson, Lehman, 2006) A related method is “acceptance and commitment therapy” (ACT) (ibid) Ellis considers ACT compatible with REBT. (Ellis, 2005)
Cognitive Load and Thought Management
Through a simple, structured approach, REBT may owe some of its effectiveness to the improved thought management that is known to some from reduced cognitive load. Although REBT does not advocate thought suppression, it may be valuable in making room for new thoughts for brief periods of time, either in-session or when consciously shifting over to rational thoughts when one finds oneself experiencing irrational thoughts. There are many studies on thought management topics that may bear upon REBT theory and practice.
Individuals most vulnerable to attachment-related anxiety and negative self-concept thoughts experienced more difficulty suppressing such thoughts under higher cognitive load. Avoidant people were the most vulnerable. (Mikulincer, Dolev & Shaver, 2004) Management of mood has been shown to be more difficult under higher cognitive load. (Wegner, Erber & Zanakos, 1993)
Criticism: Putting REBT into Perspective
Criticism of REBT theory (and overzealous application of REBT theory) points to scientifically unsupported beliefs and pseudoscience. (Wessler, 1996) The growing clinical and scientific consensus parts ways with REBT theory in the following ways (which are stated flatly as beliefs). The terms irrational and rational thoughts are used here as intended by REBT.
While theory is important in the progress of clinical approaches, the effectiveness of REBT for many problems and in treating many clinical disorders is well supported by research. Thus, the following beliefs are intended to help clinicians gain perspective and to integrate REBT effectively into their methods and theoretical orientation.
Irrational Thoughts: Irrational thoughts do not always cause emotional disorders. Emotional disorders are not always caused by irrational thoughts. Resolving irrational thoughts does not always resolve emotional disorders.
Disorders: Mood and other clinical disorders can trigger irrational belief patterns. Irrational thoughts can exacerbate clinical disorders, but do not solely cause them. Resolving irrational beliefs can have a beneficial impact on many clinical disorders, but cannot be relied on to cure them.
Child Development is Complicated: Irrational belief patterns and emotional disorders are symptomatic of the complicated process of child development as affected by genetics, other biological factors, culture, peers, and childhood experiences. Neurotic style and emotional imbalances are highly interwoven by these developmental factors.
REBT in Neurosis: Where REBT assists neurotic individuals, it frees the person from a chronic pattern. The person must have sufficient internal resources to benefit from the intervention. The neurotic thinking style does not directly cause the emotional difficulties, or exclusively maintain them as a sole cause without any reciprocity.
Logical Fallacy: When REBT uses non-cognitive strategies that result in belief change, behavior change and resolution of an emotional disturbance, it does not follow that the belief change caused the behavior change and resolution of the emotional disturbance. Rather, the relationships between these factors are reciprocal and symptomatic.
Impact of Stress: Situational stressors have a biological impact that can include causing emotional disorders. Such emotional disorders are not entirely or always (or entirely) determined by whether the stressed person thought in a rational or irrational manner.
Place of REBT Conceptual Entities: REBT concepts such as ego anxiety and discomfort anxiety function best as conceptual tools, as they are not disorders with diagnostic validity.
Potential Misuses of REBT and Similar Perspectives
Clinicians may misuse REBT by blaming legitimate concerns or fears on dysfunctional beliefs or thought patterns. This falls under the general category of psychologizing. For example, many people with fibromyalgia have been physically and psychologically harmed by well-meaning clinicians because the clinicians preferred to believe in a purely psychological rather than a medical explanation.
The problem can be more subtle than this, as occurs when both medical and psychological factors are causal. For this reason, it is important for clinicians to maintain a good grasp on the limitations of their own knowledge, and to take great care with differential diagnosis. Such care includes actually listening to their patient.
The same dynamic may occur with dangerous situations. Many people plagued by stalkers, for example, have been accused of over-reacting, when, in fact, the stalker was adept at using psychological control and terror tactics that do not appear threatening to people who aren’t experiencing them for themselves. Knowledge that stalkers may escalate their behavior and even injure or kill their victims has made even innocuous stalking a matter of concern.
REBT applied to Christianity and other Belief Systems
REBT is not a religious model. It is based on the empirical approach and Ellis considered there to be no evidence for the existence of God. However, Ellis acknowledged that some therapists have adapted aspects of REBT to their clients’ religious belief systems. In his book The Road to Tolerance, he states: "They held that several REBT values and philosophies were remarkably similar to some Judeo-Christian attitudes and therefore enhanced the mental health of the religious believers who subscribe to them" (pp. 113-14).
The fact that many clients have religious beliefs requires that therapists be sensitive to the issue. Sandra D.M. Warnock (1989), in her paper “Rational-Emotive Therapy and the Christian Client” states:
Though the psychological views of religion are varied, and whether a therapist is sympathetic, non-sympathetic or hostile toward the religions of man, he would be foolish to deny or ignore the presence of religious beliefs in the lives of clients for whom this is an issue of importance.
I once had a client who consistently brought her Bible to therapy. It was clear that many of her core beliefs were based on the existence of God, how she viewed God, and how she perceived God viewed her. I could not overlook the fact that, as someone who gained much strength from her relationship with God, her spiritual beliefs needed to be more closely examined as part of her treatment. As a Christian myself, I was able to help this client clarify some of the beliefs troubling her through a closer examination of Bible Scriptures regarding their context and meaning.
A misunderstanding of Biblical passages and concepts is often at the heart of emotional and spiritual problems for Christians. The ABC model provides even the religious person a systematic way of challenging faulty beliefs, however, the disputation (the ‘D’ part of the ABCs) is based on Biblical truths for the Christian for example, as opposed to a strict empirical approach. The idea that the REBT paradigm can be applied to Christian principles on some level is acknowledged by Warnock:
A review of the New Testament scriptures reveals the logical and rational thoughts and behaviors of Jesus. An understanding of these rational behaviors and teachings will be beneficial for the nominal Christian with emotional problems who will probably be working with limited knowledge of the scriptures, or for the strong, practicing Christian who has probably never considered that his thoughts are contrary to the life and teachings of Jesus whose life he is trying to emulate. An informed REBT therapist can use these scriptural examples to confront clients' irrational beliefs if he is equipped with this biblical knowledge.
When I had the panic attack described in the Case Illustration written about in this paper, the panic was not only about my ‘musting’ and ‘awfulizing’ the discomfort of the panic and the ego disturbances related to the loss of my business. The panic was also related to deep spiritual beliefs that had developed over a period of time. Through my failures, I had come to believe on an unconscious level that even God was somehow rejecting me and that reconciliation was impossible. These beliefs compounded the panic and, in my opinion, had to be addressed if I was truly to escape more episodes in the future. My belief was something like: “Not only do I think I am a failure, but God does as well. I will never be able to measure up and will be forever without His guidance.”
After my panic attack, I knew I needed specific evidence that my beliefs and fears about God were not true. As I began to look through the Scriptures, I was able to find many passages that spoke of God’s love and willingness to forgive my failures. On one level, I knew all of these things already, but on a deeper level I had started to believe things that were damaging and contrary to my faith. REBT provided a systematic way, through the ABC model, of regaining what I had once known before. I used Scriptures as part of my disputation of false beliefs contributing to my panic. “God has not given me a spirit of fear and I do not have to live in fear (II Timothy 1:7)” were the types of proclamations I used to combat my false ideas. For a non-believing client, this approach might seem shallow, but for many who believe in God, calling on Him for help is crucial in all areas of life, especially when we have been devastated by such things as panic attacks and other emotional disturbances.
Regardless of the belief system, therapists need to be aware that not all clients will find REBT consistent with their personal philosophy and beliefs. Therapists need to respect the beliefs held by their clients. In my opinion, an adjustment and compromise can usually be made to accommodate the divergent philosophies without completely derailing the mechanisms for change or goals of treatment.
Cognitive theory, like REBT, assumes that most psychological problems derive from faulty thinking processes. There are three bidirectional components of this theory: (1) cognitions or thoughts, (2) affect or feelings, and (3) behavior. While cognitive theory owes a debt to the behavioral model, the differences are apparent. Unlike behavioral models that focus primarily on observable behaviors, cognitive theory views antecedent events, cognitions, and behavior as interactive and dynamic. Each of these components is capable of affecting the others, but the primary emphasis is placed on cognition. The way we act and feel is most often affected by our beliefs, attitudes, perceptions, cognitive schema, and attributions. These cognitive factors serve as a template through which events are filtered and appraised. To the extent that our thinking processes are faulty and biased, our emotional and behavioral responses to what goes on in our life will be problematic. According to this theory, changing the way a client thinks can change the way he feels and behaves.
Cognitive theory was developed by A.T. Beck as a way of understanding and treating depression but has since been applied to numerous other mental health issues. Beck believed that depressed clients held negative views of themselves, the world, and their future, and that these negative views were the real causes of their depression. He found that their psychological difficulties were due to automatic thoughts, dysfunctional assumptions, and negative self-statements. Automatic thoughts often precede emotions but occur quite rapidly with little awareness; consequently, individuals do not value them highly. For example, depressed people address themselves in highly critical tones, blaming themselves for everything that happens. The following is a list of 15 common cognitive errors found in the thinking processes of individuals with emotional and behavioral problems. Similar to the list of cognitive errors developed by Ellis, there are some differences.
Fifteen Common Cognitive Errors
- Filtering--taking negative details and magnifying them, while filtering out all positive aspects of a situation
- Polarized thinking--thinking of things as black or white, good or bad, perfect or failures, with no middle ground
- Overgeneralization--jumping to a general conclusion based on a single incident or piece of evidence; expecting something bad to happen over and over again if one bad thing occurs
- Mind reading--thinking that you know, without any external proof, what people are feeling and why they act the way they do; believing yourself able to discern how people are feeling about you
- Catastrophizing--expecting disaster; hearing about a problem and then automatically considering the possible negative consequences (e.g., "What if tragedy strikes?" "What if it happens to me?")
- Personalization--thinking that everything people do or say is some kind of reaction to you; comparing yourself to others, trying to determine who's smarter or better looking
- Control fallacies--feeling externally controlled as helpless or a victim of fate or feeling internally controlled, responsible for the pain and happiness of everyone around
- Fallacy of fairness--feeling resentful because you think you know what is fair, even though other people do not agree
- Blaming--holding other people responsible for your pain or blaming yourself for every problem
- Shoulds--having a list of ironclad rules about how you and other people "should" act; becoming angry at people who break the rules and feeling guilty if you violate the rules
- Emotional reasoning--believing that what you feel must be true, automatically (e.g., if you feel stupid and boring, then you must be stupid and boring)
- Fallacy of change--expecting that other people will change to suit you if you pressure them enough; having to change people because your hopes for happiness seem to depend on them
- Global labeling--generalizing one or two qualities into a negative global judgment
- Being right--proving that your opinions and actions are correct on a continual basis; thinking that being wrong is unthinkable; going to any lengths to prove that you are correct
- Heaven's reward fallacy--expecting all sacrifice and self-denial to pay off, as if there were someone keeping score, and feeling disappointed and even bitter when the reward does not come
These thoughts are presumably automatic, over learned, rigid and inflexible, over generalized and illogical, dichotomous, and not based on fact.
Given the view that depression is determined in large part by faulty cognitions, the role of therapy is to modify the negative or self-defeating automatic thought processes or perceptions that seem to perpetuate the symptoms of depression. Clients can be taught to notice these thoughts and to change them, but this is difficult at first. Cognitive therapy techniques challenge the clients' understanding of themselves and their situation. The therapist helps clients become more objective about their thinking and distance themselves from it when recognizing cognitive errors or faulty logic brought about by automatic thinking.
Treatment, therefore, is directed primarily at changing distorted or maladaptive thoughts and related behavioral dysfunction. Cognitive restructuring is the general term given to the process of changing the client's thought patterns.
Once a specific faulty thought is identified, the therapist will challenge a client to look at alternative ways of seeing the same event. Whenever a client has difficulty changing a perception, the therapist can give him homework to test the truth of his cognitions. If, for example, a client insists that his boss hates him, the
therapist can ask him to verify this with an assignment: "Ask your coworkers if your boss treats them the same way he treats you."
Once the maladaptive thoughts are discovered in a person's habitual, automatic thinking, it becomes possible to modify them by substituting rational, realistic ideas for the distorted ones to create a happier and healthier life without substance abuse.
Generally, the therapist takes a more active role in cognitive therapy than in other types of therapy, depending on the stage of treatment, severity of the depression, and degree of the client's cognitive capability.
While Ellis and Beck have similar views about the prominent role that cognitions play in the development and maintenance of depression, their theories differ in considering how the therapist should treat irrational or maladaptive cognitions. Rational-emotive behavior therapy (REBT) is often more challenging and confronting, with the therapist informing the client of the irrationality of certain types of beliefs that all people are prone to. Beck, on the other hand, believes that the cognitive therapist, using a supportive Socratic method, should enlist the client in carefully examining the accuracy of her beliefs. Thus, Beck places more importance on the client's own discovery of faulty and unproductive thinking, while Ellis believes that the client should simply be told that these exist and what they are.
Another difference between Cognitive Therapy and REBT has to do with inferences. Inferences are negative thoughts that lead to an irrational belief, but are not necessarily false in and of themselves. For example, a person may think something like: “I will probably perform very poorly at the recital.” This type of belief is not necessarily false or irrational, but it is negative and sets the stage for the irrational belief of “and it will be the end of the world.” While Beck would probably spend some time having the client challenge this inference, Ellis would go along with the client’s inference (“OK, let’s assume you do perform poorly at the recital) and focus on challenging the irrational belief (“what evidence do you have that your poor performance will be the end of the world?”) Nevertheless, there is substantial overlap in both the theory and practice of these two therapies. Clearly, different clients will have different responses to these qualitatively different approaches to modifying their thoughts and beliefs.
Therapeutic work in cognitive therapy is devoted primarily, although not exclusively, to addressing specific problems or issues in the client's present life, rather than global themes or long-standing issues. At times, however, it is important to understand the connection between the origins of a set of cognitions and the client's current behavior. Such an understanding of how the individual got to the present emotional and behavioral state is often essential to understanding the mechanism of change. The client's attention to current problems is intended to promote her development of a plan of action that can reverse dysfunctional thought processes, emotions, and behavior--such as avoidance of problems or feelings of helplessness. Clients are enlisted as co-investigators or scientists who study their own thought patterns and associated consequences.
Cognitive therapy works under the assumption that a client can be educated to approach his problems rationally. Because of this emphasis on rational understanding, the cognitive therapist will typically begin therapy by explaining the nature of her approach:
In the opening session of cognitive therapy, the therapist will assess the client's view of his problems and their causes. The therapist pays careful attention to the meaning the client assigns to significant events and how that meaning is related to subsequent feelings and unwanted behavior. In the middle to late phases of the first session, the therapist will emphasize the collaborative aspect of the therapy process and introduces the cognitive model to the client. There are three major steps in this process:
- The therapist establishes rapport by listening carefully to the client, using questions and reflective listening to try to understand how the client thinks about his life circumstances and how those thoughts relate to problematic feelings and behavior. The client educates the therapist about himself and his problems.
- The therapist educates the client about the cognitive model of therapy and determines if he is satisfied with the model.
- The therapist asks the client to describe a recent event that has triggered some recent negative feelings, as a way of illustrating the cognitive therapy process.
Cognitive therapy tends to follow a standard within-session structure to make the maximum use of time, to focus on the most important current problems, to set the tone for a working atmosphere, and to maintain continuity between sessions. Beck structures sessions into eight elements, listed below, which he describes in greater detail.
- Setting the agenda--to focus on primary goals for treatment
- Mood check--to monitor the feelings of the client, especially changes
- Bridge from last session--to maintain continuity between sessions
- Discussion of today's agenda--to prioritize topics, avoid irrelevant tangents, determine the best possible use of time, and solicit the client's topics for discussion
- Socratic questioning--to encourage the client to contemplate, evaluate, and synthesize diverse sources of information; also known as "guided discovery"
- Capsule summaries--to maintain focus and a connection to the goals of the therapy
- Homework assignments--to serve as a bridge between sessions and to ensure that the client continues to work on problems by collecting information, testing beliefs, and trying new behaviors
- Feedback in the therapy sessions--to ensure that the client and therapist are communicating
Duration of Therapy and Frequency of Sessions
Cognitive therapy adheres to the basic goals of planned brief therapy, but treatment times can vary. It typically lasts from 12 to 20 weeks, with the client and therapist meeting once per week. However, it can be conducted in less time--for instance, once per week for six to eight sessions. The number of sessions will depend on the nature of the problem.
Because cognitive therapy is usually planned for comparatively short treatment times, there has not been much research to study the relative effectiveness of longer term cognitive therapy. However, Lyons and Woods in their meta-analysis of 70 different rational-emotive therapy studies found that increased effects correlated with longer treatment times (Lyons and Wood, 1991). More research needs to be conducted looking at the effect of treatment duration on the efficacy of these therapies.
Cognitive therapy can be quite successful as an option for brief therapy for several other reasons.
- It is designed to be a short-term approach suited to the resource capabilities of many delivery systems.
- It focuses on immediate problems and is structured and goal oriented.
- It is a flexible, individualized approach that can be adapted to a wide range of clients, settings (both inpatient and outpatient), and formats, including groups.
Example of Disputing Irrational Beliefs Fostering Client’s Alcohol Abuse
Rational Alternative or Dispute
Drinking is never a problem for me, even if I do lose control once in a while. It's other people who have a problem with the way I drink.
Losing control can be the first sign of a problem, and if my drinking is a significant problem for others, sooner or later it will be for me.
I need to use drugs to relax.
I want to use drugs but don't have to use them just because I want to.
I can't stand not having what I want; it is just too hard to tolerate.
I may not like it, but I have stood it in the past and can do so now.
The only time I feel comfortable is when I'm high.
It's hard to learn to be comfortable socially without drugs but people do so all the time.
It would be too hard to stop drinking. I'd lose all my friends, be bored, and never be comfortable without it.
While stopping drinking and doing drugs might cost me some things and take time and effort, if I don't, the consequences will be far worse.
People who can't or don't drink are doomed to frustration and unhappiness.
Where's the evidence of that? I'll try going to an Alcoholics Anonymous meeting and do some research on how frustrated and miserable these nondrinkers actually are.
Once you've stopped using and you see it's all over, you're right back to where you started, and all your efforts only lead you to total failure. Once an addict, always an addict.
A slip is only a new learning experience toward recovery. It is not a failure, only a setback that can tell me what direction I need to go in now. It's my choice.
Example of Introducing Client to Cognitive Therapy: A Sample Script
"I want to spend a few minutes telling you about my approach. Basically, it comes from the observation by many people that our feelings and behaviors in particular situations follow directly from how we think about these situations. My goal in working with you is to focus on trying to understand how you see things--the important things in your life that are related to substance use--and to help you look at them objectively and honestly. We may find that you are seeing them correctly, and we'll have to address these realities. Sometimes, though, people get into automatic ways of thinking about themselves and their situation without examining them more carefully. Let's look at these possibilities and see if they can be changed to help you. How does that sound to you?"
REBT and CBT provide many helpful perspectives and guidelines as a form of cognitive behavioral therapy that can integrate well with other approaches in an eclectic practice, provide very compelling and motivational metaphors for clients, and provide structure and focus to treatment. Many of the pioneering ideas of Albert Ellis continue to have a profound influence on psychology and psychotherapy outside of REBT.
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