Rational-Emotive Behavior Therapy

History

Rational-Emotive Behavior Therapy (REBT) is the earliest formal cognitive behavioral psychotherapy (CBT). Its premise is that treatment can dramatically improve emotional and mental health by altering patterns of thinking. Albert Ellis developed this approach in the 1950s because of his dissatisfaction with psychoanalytic approaches prevalent at the time. He was a psychoanalytically trained psychologist. He felt that his patients could progress much faster than was possible through psychoanalysis. The approach uses a much more directive approach than was accepted at the time. This includes liberal use of psychoeducation. Ellis first referred to the approach as rational therapy, and then rational-emotive therapy (RET)

Ellis (1994) puts this approach into perspective by stating 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."

Ellis distinguishes REBT from earlier approaches, referring to its "de-emphasis on early childhood, emphasis on deep philosophic change and scientific thinking," and the "use of psychological homework." (Ellis, 1994)

A second CBT emerged roughly ten years later. Its originator, psychiatrist Aaron Beck, called it cognitive therapy (CT). According to Ellis, these early CBTs spawned the CBT movement, which grew dramatically in the 1980's and 1990's into what he called "the cognitive revolution." (Ellis, Bernard, 2006).

In the beginning, the field of psychology scorned Ellis. However, his impact on the field was well recognized by 1982, when a poll of psychologists placed his influence on the field above Freud. (Kaufman, 2007)

Although behaviorism contributed to Ellis' ideas, went beyond a purely behavioral approach. In contrast with psychoanalytic thought, he emphasized our conscious and rational abilities. He felt that conscious and nearly-conscious beliefs were meaningful and he addressed them directly.

Ellis was also influenced by Greek stoicism, and stated that it was, "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, 1994)

Roots in Philosophy

Ellis felt that Greek Roman stoic Ecpictetus was one of the greatest originators of the core concept of CBT, that of cognitive restructuring. Ecpictetus said, ""Man is disturbed not by things, but by the views he takes of them."

Ellis points out that Marcus Aurelius, based his life on the principles that Ecpictetus developed. Ellis felt that Aurelius' book Meditations. (Aurelius 2006) embodied these principles. Aurelius was a highly regarded Roman emperor in the second century. (Birley, 2000, p. 8)

It is very interesting to cull out these principles from the writing of Aurelius, which casts a wide net, as shown in the following passage:



Theory Overview

Albert Ellis (b. 1913), widely known in therapeutic circles for his flamboyant, often confrontational counseling style, founded "REBT," or rational-emotive behavior therapy (Corey, 2005; Fadiman & Frager, 1994). REBT stresses the contribution individuals make toward their own psychological problems, primarily by how events are interpreted (Corey, 2005).

Advocates of REBT feel that some have criticized REBT based on an oversimplified idea of REBT. Instead, these advocates state that the approach has philosophical depth, and is based on humanistic values that lead to individualized work carried out in a collaborative manner that is tailored to the client's perspective. (Ellis A., Abrams M. & Abrams L., 2008) While the theories of REBT give the impression that it exclusively works on a rational basis, REBT therapists state that the approach includes emotional and behavioral elements, and the theory sees all these elements as interrelated.

Therapy focuses on changing negative attitudes and dysfunctional beliefs held by the individual (Van Voorhis, Spruance, Ritchey, Listwan, & Seabrook, 2004) and places emphasis on the interaction between cognitions, emotions, and behaviors (Albert Ellis Institute, 2005; Corey, 2005). Ellis feels that beliefs and interpretations of events precede our emotions and actions and felt that therapists needed to help clients learn to modify these dysfunctional interpretations and beliefs (Corey, 2005; Fadiman & Frager, 1994).

As modifications in beliefs occur, changes in emotions and actions will follow (Albert Ellis Institute, 2005; Fadiman & Frager, 1994). Ellis' views the therapist as a teacher and therapy as an "educational process," rather than one that focuses on talking and expression of feelings (Corey, 2005, p. 272).

REBT aims to improve emotions and behavior through change of "core beliefs." As a theoretical orientation, REBT embraces the biopsychosocial model that embraces the interplay of biology, psychology and sociology in mental and physical health. This model is viewed as a perspective for enhancing human behavior and subjective experience.

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."

Among REBT's characteristics that were radical at its inception are dispensing with self-evaluation. Instead of direct efforts to improve client self esteem, REBT asserts that clients should learn to refrain from making general evaluations themselves and others. This is intended to stop dramatic, harmful reactions that REBT sees as causing clients' difficulties. REBT was also radical in its creation of an active role for clients to take in fostering their recovery.

According to REBT dysfunctional belief system are dynamic and require maintenance. It sees dysfunctional beliefs as beginning in early childhood, but not as sustaining themselves automatically. This is seen as an opportunity to successfully confront them through rational analysis and other methods.

The result is the elimination of dysfunctional beliefs and their chronic negative impact. This equates to a deep philosophical shift.

The key beliefs that are targeted are those that revolve around ones life, identity, or the world. Clients are trained to take a scientific stance as they are taught to test their beliefs as a scientist would test a hypothesis. REBT practitioners state that clients do not have to have special gifts to do this. REBT has reportedly been successful with clients who are cognitively impaired or even psychotic.

To craft these profound changes into a durable way of life, Ellis (1994) asserts, the client must work. To further this work, homework is important. Ellis was adamant that mere insight is not adequate, 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 holds that irrational beliefs create a snowballing or feedback effect with the occurrence of secondary disturbances. These include feelings of excessive guilt or shame about having their problem. Targeting such secondary reactions helps to stabilize the client's emotion early in treatment, and improve the odds of success.

One of the cornerstones of REBT is its anxiety model. It distinguishes between two types: ego anxiety and discomfort anxiety. REBT treats these anxieties as discrete dysfunctions originating in the kinds of dysfunctional beliefs that REBT addresses.

Dr. Ellis

Dr Ellis was born September 27, 1913. Because of the impact of REBT, Albert Ellis is considered the grandfather of CBT. He received many awards including the major award of the American Psychological Association for Distinguished Professional Contributions to Knowledge and the Humanist of the Year Award of the American Humanist association.



Dr. Ellis died in July of 2007 in his home above the Albert Ellis Institute. He was 93. To describe Dr. Ellis, his New York Times obituary read, "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)

REBT vs. CT

Cognitive therapy (CT) was developed by Aaron Beck in the 1960s. The two approaches are nearly identical theoretically. Their differences are more a matter of emphasis. Perhaps the major distinction is that CT does not focus on the "must" or demandingness aspect of dysfunctional beliefs. CT casts a somewhat wider net in terms of the categories of dysfunctional beliefs, and does not specify a small number of underlying core beliefs or thinking styles as REBT does. CT does not directly confront the underlying demanding implications of the beliefs, instead taking a more Socratic approach that enlists the client in a fuller dialog and working through process. Another major difference is that CT does not intently attempt to impress upon the client the unconditional self acceptance of REBT.

All of this results in more general disputation during CT; a broader array of cognitive restructuring efforts in service of the client's goals. Where REBT might focus on the demanding aspect of a substance abuse client's desire to use drugs, getting to, "if I don't use drugs I won't handle it, it's the end of the world," CT might seek to establish a variety of cognitions supportive of recovery, initially getting to cognitions such as, "if I go to an NA meeting, I can see whether people abstaining from drugs are at the end of their ropes," rather than seeking to directly confront the awfulizing. Thus, the client is invited to test hypotheses.

Research on REBT

Research on REBT has shown good results for many diagnoses and goals, and has a substantial base of supportive research. (ibid; Colin, 1997; Leichsenring, Hiller, Weissberg, & Leibing 2006)

More generally, CBT has shown efficacy in numerous studies and for diverse issues. (David, Szentagotai, Eva & Macavei, 2005) Research on REBT constitutes only a fraction of studies on CBT, because there are other forms of CBT and CBT is a more general category that is more likely to be subjected to research. Although REBT gave birth to CBT, in most CBT research it is not possible to tell how much fidelity the forms of CBT studies have to REBT. CBT research has not generally shown a significant and reliable difference in effectiveness between the forms of CBT.

Froggatt (2005) offers the following list of disorders and subclinical problems as being typically accepted as appropriate for treatment with REBT. The author includes citations of some REBT research pertaining to some of the categories as well.

• Anger management and antisocial behavior
• Anxiety disorders, including PTSD
• Child or adolescent behavior disorders
• Coping with chronic health problems, a physical disability, or a mental disorder
• Depression
• Eating disorders, addictions, and impulse control disorders
• Pain management
• Personal growth
• Personality disorders (Leichsenring & Leibing, 2003)
• Relationship and family problems
• Sexual abuse recovery
• Social anxiety (Mersch, 1995)
• Stress management
• Type A Behavior (M?ller & Botha, 1996)
• Workplace effectiveness

Two meta studies on REBT are reported on by David, D., Szentagotai, A., Eva, K. & Macavei, B. (2005) Over 300 studies on its clinical application were involved. Diagnostic Category includes diagnostic categories that showed good effect sizes. Outcome Measures shows studies whose outcome measures are not necessarily for diagnoses.

Diagnostic Category

• 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)
• Neuroticism
• 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)

Outcome Measures

Fear/anxiety

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)

Neuroticism

Rationality

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 metastudy discovered REBT to have effect sizes stronger than other approaches, with the exception of behavioral therapies. The weaker approaches included, "psychodynamic, gestalt, humanistic, Adlerian, reality therapy, undifferentiated counselling, vocational and personal development counselling." (ibid)

The authors offered the following 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

Cognition in Human Behavior and Emotional Well Being

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.

Referring to it as "stupid behavior by a non-stupid person," Ellis (1993) was bringing attention to the covert nature of irrational beliefs, in that they can go uninspected it people who are capable of thinking in much more productive and sophisticated ways. He referred to the persistence of irrational beliefs and behavior as "drifting" or "goofing."

Understanding the Irrational Code

The Self-Defeating Nature of Irrational Beliefs

REBT introduces clients to the idea irrational beliefs, but refers to them as self-defeating beliefs. This term emphasizes the role of irrational beliefs in preventing clients from resolving their problems. In turn, these beliefs make up the dysfunctional thought patterns targeted by REBT. (Froggatt, 2005)

REBT articulates the destructive nature of irrational beliefs with these criteria: Froggatt (2005):

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.

Core Irrational Beliefs

Ellis (2003) felt that all irrational beliefs could be characterized by one of three core irrational beliefs. He felt that one of the three could serve as a template for many variations. By characterizing the belief in simple terms, he made it more obvious why it was harmful. They are: (ibid)

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.

Each of these core irrational beliefs express fundamental postures that give irrational thoughts their destructive power. They are: (Perkins, 2007)

1) An unrealistic demand that the person places upon oneself, others, or the world, to be different than they are, and one of the following:

2a) Low frustration tolerance, or

2b) Awfulizing, or

2c) People rating

Ellis has also boiled down irrational beliefs into three core assumptions (Fenichel, 2000):

I must do well

You must treat me well

The world must be easy.

Underlying Thinking Styles

Evaluative Thinking in Irrational Beliefs

Clients may feel very motivated to defend their irrational beliefs based on any truths they contain, or their value in expressing upset. However, fundamental characteristics of irrational beliefs ensure that they will also be destructive.

They include demandingness, awfulizing, discomfort intolerance and people-rating.

Demandingness, also referred to by Ellis as "musturbation," expresses or implies demands about oneself, others, or the world. By "the world," Ellis refers to situations or events. The client scales these demands into absolute necessities (Froggatt, 2006). This results in inevitable emotional and behavioral disturbances when these rigid expectations go unmet or are violated. This disturbance may escalate the clients need to make demands.

Awfulizing exaggerates the negative significance or consequences of what the client is judging. The resulting emotional disturbance prevents creative or otherwise resourceful thinking and behavior, thus preventing solutions and creating a vicious cycle of disappointing situations and reactivity.

Discomfort intolerance turns an undesirable situation into torment.

This reactivity, as with the previous two characteristics, blunts resourcefulness and rigidity. One REBT client presented with the inability to tolerate knowing that the universe was expanding.

People-rating applies an extreme, global, negative evaluation to oneself or others. It is often expressed as a negative, judgmental label, expressed as thought it could actually characterize the person in their entirety. REBT has even applied this perspective to the tendency of depressed clients to refer to themselves in demeaning terms such as "worthless." This is taken to be people-rating in the form of an attack on the self for failure to achieve perfection. The demand is said to perpetuate the depression.

Inferences and Evaluations: Understanding Cognitive Patterns
The evaluative thinking that constitutes irrational beliefs is supported by two deeper levels of thought.

Inferences as facts are unspoken opinions regarding the situation or a guess as to what has happened. The client's dysfunctional thinking converts these opinions or guesses into perceived facts. REBT side steps any confrontation with these "facts," because this would lead to an unproductive struggle with an unlimited number of these dysfunctional inferences. Attention is directed instead to dysfunctional core beliefs.

Global or Extreme Evaluations is deeper than inferences. Evaluations are the significance that the person assigns to a situation, themselves, or another person. For example, if someone were to cut the client off in traffic, the client might evaluate the person as being a jerk. As opposed to a person expressing a fleeting epithet, the client would actually believe that the other driver's global self is a jerk. This leaves unspoken and only dimly thought out many questions such as what rights a jerk has, how society should treat such a person, and what rights the client has to punish or police the other driver for being a jerk. This can lead to poorly thought out driving maneuvers and hand signals that lead to further conflict or accidents.

Useful in Treatment: Twelve Irrational Beliefs

It is instructive to review an earlier list of irrational beliefs that Ellis (1994) created. These irrational beliefs are closer to those expressed by clients, but are still framed to display their irrational nature, as were the three core irrational beliefs. This list is very useful for work with clients.

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 masturbatory hypotheses which we often employ to create them.

A Fundamental: Anxiety

REBT holds certain forms of anxiety as being key to neurotic disorders in general, not just disorders of anxiety. It posits two major anxiety types.

Ego anxiety (EA) is the anxiety that results from a perceived threat to one's identity or self worth. This corresponds to an unrealistic level of demand upon the self that, "they should or must perform well and/or be appreciated by others..."(Ellis, 1994) This is compounded by the irrational belief, "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)

Of the two, EA is the most potent as an important contributor to many emotional problems, such as, "severe depression, shame, guilt, and inadequacy and frequently drives people to therapy (or to suicide)." (Ellis, 1990)

Discomfort anxiety (DA) is anxiety over the possibility of a threat to some aspect of one's comfort, expressed as 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 intense reactivity to these deviations from their comfort demands is expressed as, "it is awful or catastrophic (rather than merely inconvenient or disadvantageous)." (ibid)

DA is less dramatic than EA, but is more common. EA can be a primary or secondary cause that makes emotional problems more intense. As a vicious cycle, it also makes them more persistent. In other words, it makes them anxious about their anxiety.

DA arouses emotional difficulties such as, "feelings of anxiety, depression or shame." (ibid) This includes the intensifying of fear regarding normal, but potentially dangerous, situations. This can lead to phobias for situations such as elevators or driving.

The relative subtlety of DA causes people suffering from it to insist that the situation is the problem, oblivious to how their own beliefs are contributing to the anxiety. Ellis felt that clinicians would mistake the client's anxiety as a trait, missing its dynamic and treatable nature.

Because these anxieties have the common denominator of core irrational beliefs, the can generalize to yet more situations. For example, the person afraid of elevators may become fearful of shopping, where escalators and elevators are involved. This can expand into fear of driving or going downtown. The result can be extreme limitations in life.

Froggatt (2005) further divides DA into two "flavors" of low frustration tolerance (LFT) and low discomfort tolerance (LDT), stating that they, "...are similar and closely related."

Low frustration tolerance is an entitlement to convenience, implying that one should not have to experience any form of frustration. Discomfort in the form of frustrations is translated instantly into a terrible injustice or a torment.

The automatic nature of these thoughts often takes the form of unspoken, semi-conscious assumptions and emotional reactions that go unspoken. An important goal of REBT in this respect is to assist the client in making these irrational beliefs and stances conscious. Progress can occur simply because the client, upon verbalizing an irrational belief, can see plainly its irrationality. This leads to the capacity and willingness to entertain other ways of framing their situation, including adopting rational beliefs with the assistance of the therapist. The client's improved functioning and feelings lead to yet more motivation to adopt resourceful beliefs and self talk.

Discomfort disturbance, Froggatt says, takes form in one or more of the following symptoms:

'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; practicing 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, over concerned with unfairness, and prone to making comparisons between one's own and others' circumstances.

Ellis suspected that discomfort anxiety has evolutionary roots, reflecting the survival need implicit in having to control the environment to meet real needs for safety and well being.

Phobias, Ellis postulates, occur in people who have stronger physiological reactions. He sees phobic individuals as a subtype that has greater difficulty in directly dealing with their anxieties. He stated that REBT, for these clients, could be helpful for phobias, but generally only as an adjunct. He felt that the physiological reactions of this subtype might explain the value of exposure therapies, such as those developed by Wolpe. Exposure therapy involves structured, incremental exposure to the situation or stimulus that the client fears. (Ellis, 1990)

Eccentric or Magical Belief Systems, offer an escape from anxiety, and so are very attractive to people with anxiety. Such belief systems often offer protection from harm through supernatural means. When some aspect of the belief system reduces their anxiety, this can constitute validation of the entire belief system. Ellis felt that certain faddish approaches to psychotherapy such as primal scream can attract people in the same way.

An Example

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) shows how a single irrational belief can take the form of an ego anxiety and a discomfort anxiety. He offers the following irrational belief. "I must get good results at the things I do, especially in producing adaptive feelings."

He then offers a discomfort anxiety interpretation "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!" and an ego anxiety interpretation. "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!"

REBT treats each of these separately, focusing on the discomfort anxiety as a means to prevent recurrence of the ego anxiety.

Multi-Modal Approach

The emphasis of cognitive therapies on cognition, as well as typical basic reviews of REBT may give the reader the impression that REBT focuses exclusively on cognition. However, according to Ellis, (2006b)

"In Rational Emotive Behavior Therapy I combined thinking and philosophy for the first time with feeling - emotion - and also with behavior therapy, which I got from John B. Watson, Fred Skinner and others.

"So it's one of the very few therapies that is multi-modal in Arnold Lazarus' sense, and it includes thinking, feeling and behavior, and has about 20 or 30 techniques under each heading; it has lots of evidence in favor of it."

Criticism: Putting REBT into Perspective

There is scientific and clinical criticism of the theories of REBT that cannot be written off as mischaracterization. (Wessler, 1996) As with any theoretically-based approach, it is helpful to distinguish between the effectiveness of the method, and the theory used to develop and support the approach. Even though a theory is highly effective as a therapeutic tool when translated into lay terms, it may not stand under scientific scrutiny. Understanding the ways that a clinical theory falls short can serve in the further development of clinical approaches spawned by that theory. This is not merely an academic exercise. It can have serious ethical and clinical implications.

Potential Misuses of REBT and Similar Perspectives

Clinicians must take care not to misuse REBT theory by blaming legitimate concerns or fears on dysfunctional beliefs or thought patterns (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. So-called invisible disorders such as fibromyalgia and cognitive deficits are vulnerable to psychologizing and accusations of malingering. Therefore clinicians must take care to be aware of the limitations of their knowledge and biases, and carefully undertake differential diagnosis.

Arrow of causality pertaining to irrational thoughts and disorders

The basic tenet of REBT, that thoughts cause emotional distress and behavior problems, oversimplifies psychopathology. Biological insights have expanded our understanding of the nature of mental health problems far beyond that model.

Research is showing us how biological factors such as genotypes and excessive stress create a vulnerability to or cause depression and anxiety. (Solvason, Ernst & Roth, 2003; Southwick, Vythilingam & Charney, 2005) Reversing REBT's arrow of causality, it is now accepted that depression can not only lead to irrational thoughts such as extreme self deprecation, but even delusions in psychosis. 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. Treatments that affect mental state such as EMDR can cause surprising improvements to the content of thought with little or new cognitive work. Research is showing genetic inheritance is a strong factor in producing violence in adults.

Since neurobiological vulnerability to emotional disturbance such as situational stress, genetics, and cognitive disabilities are not factored into classic REBT theory, it does not account for emotional problems that were not initiated by irrational beliefs. This creates a risk that an overzealous practitioner of REBT could neglect etiology and fail to treat or refer according to accepted clinical and ethical standards.

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. There is little research on or use of REBT for psychotic disorders. However, CBT and CBT-influenced treatment and support are showing promise for biological disorders as they evolve to accommodate emerging knowledge. For example, cognitive work is showing promise in OCD. Much like REBT theory functioning as a treatment tool, neurological knowledge and brain scan images are being used in a cognitive approach as tools for persons with OCD.

The reciprocal interaction of variables runs counter to a single arrow of causality. For example, Southwick, Vythilingam & Charney (2005) state that, "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."

Oversimplification of child development

Irrational beliefs are thought to have their origins in the indoctrination of children. Working backwards in REBT theory, this leads one to state that since emotional problems are caused by irrational beliefs, and irrational beliefs are caused by childhood indoctrination, then adult emotional problems are caused by childhood indoctrination. Given the complicated and interactive nature of child development, REBT does not offer much insight into child development. And child development does not factor as a large component of REBT theory.

Diagnostic vagueness

According to Harrington (2006), discomfort anxiety is used to guide assessment and treatment, but has received little direct attention from researchers as to their diagnostic utility or validity. The content of beliefs associated with these anxieties has not been analyzed in research.

However, Harrington suggests that this deserves more attention, because of his research showing the impact of irrational beliefs as being separate from other factors associated with emotional disturbances. In researching "a multidimensional Frustration Discomfort Scale (FDS)," he found that that, "FDS sub-scales were differentially related to specific emotions, independent of self-esteem and negative affect. The entitlement sub-scale was uniquely associated with anger, discomfort intolerance with depressed mood, and emotional intolerance with anxiety."

Updating REBT

The value and popularity of REBT has given it the durability to continue with proponents who update the theories and practices of the approach. While there are criticism of the theories of REBT, it appears that REBT will evolve rather than fade in the face of progress in psychological theory.

Albert Ellis, founder of Cognitive Therapy, expressed some concern that REBT's roots in "the pre-scientific era" were continuing to hold it back from scientific adaptation. (Fenichel, 2002)

REBT Evolving

There is ample reason to believe that REBT can continue to flourish while embracing new knowledge. It is also influencing other treatment approaches for populations that REBT has not traditionally treated. The REBT Institute has even published a commitment to maintaining REBT as an open approach that integrates new findings. (REBT Institute, 2009):

As far as possible, maintain the philosophy and uniqueness of REBT while advancing the system through incorporating evidence-based enhancements, and through applying and testing measurable innovations that are consistent with the mission."

Conversely, the influence of REBT shows in CBT-informed approaches that have been developed in more recent years. A good example can be found in manualized approaches to psychoeducational group treatment for severe problems including borderline personality disorder and severe mental illness, including schizophrenia. For example, a major influence in the American mental illness recovery movement is an approach to rehabilitation that offers a formula for preventing relapse that resembles the ABC approach of REBT. However, it is expanded into a larger framework that puts a more formal emphasis on contextual stressors and supports.

Those elements are Triggers (similar to activating events), Early Warning Signs, internal (corresponding to Beliefs, but including not only thoughts, but other sensory experiences), Breaking Down (corresponding to Consequences, but with the emphasis on the experience of people with mental illnesses). (Copeland, 1997)

Similarly, the combination of somatic and cognitive behavioral elements in eye movement desensitization and reprocessing (EMDR), a treatment highly researched in post traumatic stress disorder (PTSD), shows the influence of REBT. A key aspect of EMDR lies in overcoming "negative cognitions" and supplanting them with "positive cognitions" that have both conscious and visceral validity. (Shapiro, 2001)

Evolutionary and Social Psychology

Major factors that will influence REBT and psychotherapy in general are found in evolutionary psychology and social psychology. Specifically, in research on persuasion and automatic behavior triggers. Evolutionary psychology proposes that many of our drives, behaviors, and even emotional problems have a strong genetic basis. It is a complicated issue, because of the interplay between our biological inheritance and other factors such as learning, trauma, and interaction with society.

The implications of evolutionary psychology for social psychology in helping to explain phenomena such as persuasion, conflict, and stigma, has much potential significance in the further evolution of REBT and psychotherapy in general. Dryden (2003) offers a detailed treatment regarding the place of these theories in REBT. She explains the underlying thinking styles and specific emotional disturbances of concern in REBT as resulting from evolutionary pressures, that is, their value in species survival. For example, she translates "musts" in this fashion, tying attitudes such as demandingness to evolutionary needs such as preventing encroachment.

A basic premise of this thinking is that our genetic agenda can be at odds with our individual survival and happiness. At the minimum, by using this concept as a source of reframes for REBT, we can enhance its value and flexibility. Additionally, these insights can help us identify irrational beliefs and show ways that these beliefs and their underlying drives can have meaningful, constructive expression.

By helping clients to see "the 'mismatch' between our evolved basic biology and psychology and our current social, economic and practical environment," (ibid, p. 225), we can help clients see that their irrational beliefs are, in part, expressions of those drives. This, in turn, helps them see the importance of redirecting these primitive drives into more functional behavior.

Regulation of Evolutionary Drives

At the minimum, REBT can gain perspective from understanding how brain dysfunction and drive dysregulation have implications for treatment planning. In viewing depression, a syndrome widely accepted as a fundamentally biological phenomenon, Dryden (2003) sees a breakdown of normal defenses that appear to help channel our drives. Social psychology tells us that people tend to blame others for their problems, and blame situations for their own. In the case of depression, this defense is not active.

She also sees activation of social status and threat issues. It appears that the internal pressure to retreat from circumstances in which one cannot compete takes on an extreme level of activation. At the same time, depression exacerbates "involuntary subordinant self perception." From an evolutionary perspective, this drive is a means of preventing excessive social conflict by causing people to comply with the expectations of a lower social status. In depression, it appears to manifest in extreme self-deprecation. This is not to deny the biochemistry of depression, but to add dynamics that interact with and can even exacerbate dysfunctional biochemistry.

It may be that brain impairment plays a part. Brain impairment is implicated in inadequate regulation of primitive drives. This theory attempts to help explain behaviors such as those of obsessive compulsive disorder, which may express primitive urges behind stereotypic behaviors such as preening, as well as threat detection and prevention. (Kaminer, D, & Stein, D. J., 2004) This theory suggests that poor regulation of evolutionary drives such as those Dryden points to contributes to the internal pressure and emotional intensity of irrational beliefs. The identification of consistent OCD symptoms across cultures contributes to this idea. There is work on identifying endophenotypes that are vulnerable to OCD symptoms.

One of the largely biological factors that may have a great influence on the ability to participate and benefit from treatment can be found in research on secure base priming. People primed with positive attachment-related thoughts tend to be more open-minded and cooperative. (Mikulincer, Hirschberger, Nachmias, Gillath, 2001) (Mikulincer & Shaver, 2001)

Social Psychology of Persuasion

Research on persuasion and triggers of automatic behavior in humans appears to be a resource for REBT in helping clients resolve irrational beliefs. The longstanding nature of irrational beliefs suggests that they are housed in implicit memory. This form of memory creates a sense of knowing and great resistance to being dissuaded from such "knowledge." (Cialdini, 2008)

The social psychology of persuasion has focused attention on many persuasion methods that are relevant to this tendency. Such persuasion methods also involve triggers of internal pressure to act out automatic behaviors. Such behaviors are suspected to have strong evolutionary roots because of their automaticity and the directness with which they are triggered by specific stimuli. (Cialdini, 2008)

Methods of REBT overlap those discussed in this literature. Further study of this literature could lead to additional persuasion methods for reducing irrational beliefs, for increasing motivation for treatment, and for developing functional beliefs and behavior.

Cognitive therapies may improve their effectiveness through greater understanding of culture and stigma as triggering biologically-based pressures. Because of its focus on the individual, REBT has not given detailed attention to the vulnerability of beliefs to such factors. An example of the power of social stigma took place in Fiji, when eating disorders precipitously increased after television became available there. (Becker, Burwell, Herzog, Hamburg & Gilman, 2002)

REBT stands to benefit by systematically integrating the growing knowledge of how to scientifically engineer persuasion, especially since REBT places so much emphasis on getting changes in commitments, shifts in identity, and establishment of new consistent behaviors. All three of these factors are addressed in the use of automatic behavior pressure that is believed to draw upon evolutionary drives.

REBT Therapy Methods

There's a Method to His Theory

It bears repeating that REBT theory itself is an important part of its method. It not only guides clinician behavior, but is translated into lay terms and constitutes the educational content that occupies so much of REBT treatment. Clients are given to understand that they are beginning to take responsibility for their treatment and their lives by learning to grasp and apply this information.

The information is designed to give clients the capacity to gain some objectivity in assessing and critiquing their irrational thoughts. With the emphasis on thoughts, there is no need to criticize client behavior. Behavior tends to change as irrational beliefs give way to functional ones.

Phases of REBT Treatment

REBT requires that the therapist be empathic, warm and respectful. The first phase of treatment getting the client engaged is very important.

The second phase is the initial assessment, in which the clinician determines whether the client may benefit from REBT. As the therapist reviews the problem and situation, they discover the beliefs underlying the problem and how the client holds to those beliefs. The belief that buildings are too dangerous may yield easily, while the client may defend their belief in the danger of elevators. The therapist explores the underlying levels of thinking, such as the client's attributions, as mentioned earlier.

The therapist also looks for secondary disturbances that can pose obstacles to therapy. For example, a highly self-critical client about their need for therapy, suggesting that ego anxiety is in the foreground. It suggests that depressed, self-defeating core beliefs will need to be addressed.

The therapist also prepares the client to participate in therapy through treatment planning and initial education. Treatment planning is a collaborative process in which therapist and client determine their treatment goals. The goals are sufficiently concrete and specific that they can help motivate the client and lend to the client's vision for good results upon completing therapy.

The therapist provides initial education about REBT. This material is intended primarily to enhance the clients motivation and ability to participate. To build rapport and momentum, the therapist avoids detailed, scientific explanations. REBT relies on descriptive metaphor and language that promote understanding and engagement.

The third phase implements the treatment, and this is where most of the treatment occurs. Much of the treatment revolves around analyzing dysfunctional feelings and behavior, and creating "ah-ha" experiences in which the client finds ways to convert their dysfunctional thoughts, feelings, and behavior into happiness and success. The therapist reinforces all progress to enhance motivation.

The fourth phase occurs throughout the treatment and termination phases. In it, progress is evaluated. When appropriate, termination is planned.

The fifth phase is termination. The client is prepared to respond to any setbacks and unexpected challenges. The client learns that it is not a failure to return to treatment as needed. Given the clients' propensity for global, negative self-evaluation, this is an important step.

Ellis states that clients must work very hard in many cases, and that they must make a life-long discipline of eliminating the impact of irrational beliefs in their lives. (Fenichel, 2002)

From Philosophy to Action

Ellis (1994) emphasizes the importance of philosophy in his development of REBT, and in helping clients to understand the significance of REBT. He stated, "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."

In keeping with this philosophy, clients learn to cease self-rating, and recognize that global, negative self-rating is harmful. They are helped to identify and resolve habitual negative self-rating.

With improvements in self-esteem, clients are in a position to take on irrational core beliefs. They are guided to adopt functional beliefs.

The Approach to Self Esteem and Core Beliefs

Successful REBT clients learn to improve self-esteem by upgrading irrational core beliefs into functional ones. This requires becoming aware of semi-conscious or unconscious beliefs. REBT has a variety of methods to achieve this. REBT fosters a sense of self-efficacy and responsibility, and encourages hard work in making these changes.

One of the most basic REBT techniques consists of questions from the therapist intended to help the client put feelings into words. The therapists ask questions such as, "What does that mistake of yours mean about you?" and "What do you think people may believe about someone who does that?" The goal is to get to simple, core beliefs such as, "I must be perfect, or else I am a worthless failure and will be scorned by others."

Clients can easily see the irrationality of beliefs brought into such blatant terms. A choice between two extremes of being of no worth and being perfect is not a valid one. The therapist also helps clients see how the effects of irrational beliefs pervade and harm their lives.

Core Beliefs as Rules

REBT shows client that their irrational beliefs function as rules that limit them by creating rigid behavior patterns. This reframe helps clients see their irrational beliefs as arbitrary and irrelevant.

REBT helps clients see how these beliefs trigger emotional upset and counterproductive behaviors in response to violations of their dysfunctional rules. The therapist brings clients' attention to their automatic, unconscious conversion of desires and preferences into "musts." This conversion process becomes a target of treatment. Clients are assisted in gaining control over this reactivity, to redefine their "musts" as preferences.

As clients experience success in managing their thoughts, they experience the emotional and behavioral benefits that result. This enhances their sense of self-efficacy, improving self-esteem, creating a positive cycle that feeds client motivation and performance in REBT.

Additional Exacerbating Factors Ellis recognized that external stresses can take their toll, but pointed out that stressful life circumstances are exacerbated by irrational beliefs. Dysfunctional emotional and behavioral reactions that result can only compound circumstances such as those of poverty.

Ellis has speculated that those most vulnerable to adverse circumstances also have greater genetic vulnerability to the factors that REBT holds accountable for emotional destabilization.

Anxiety and depression can cause ongoing decrements in cognitive processes in people without preexisting cognitive problems. (Eyesenck 1992) Such deficits can not only directly contribute to anxiety, but can also increase the challenge of identifying and resolving irrational beliefs.

Research by Seligman and others has brought attention to the phenomenon of learned helplessness, a state in which an animal or person will experience apathy and cease attempts at controlling their environment. (Martin-Krumma, C. P., Sarrazinb, P. G., & Peterson, C., 2005) This results from circumstances in which a person experiences repeated negative stimuli but is unable to control those stimuli for a period of time. Further research into this has shown that "explanatory style" can mitigate against or worsen learned helplessness. Explanatory style refers to the way the person describes their involvement in their circumstances and the meaning of their circumstances.

Those whose explanatory style regarding negative circumstances characterized them as

Those who did not tend to take negative circumstances personally, or see them as pervasive or permanent, tended to fare much better than those to did not. This conforms to the REBT model of thinking styles that underlie irrational beliefs, in which people perceive negative circumstances as a violation of their rules (personal), and making global interpretations (pervasive and permanent).

Activities in REBT

Below is a number of activities typically used in REBT. Each activity contains some of the effective ingredients of REBT.

ABC's of REBT

One of the most familiar techniques of REBT is education, and the most familiar educational tool is the ABC's of emotional disturbance, explained earlier. This section will show an example of how a client might complete these ABC's. This example 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 drawn from a clinician's handout. (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. Consequence (my reaction)

Feelings: Hopeless, depressed.

Behavior: Withdrawn, pensive, fatigued, unclear, distracted, overeating.

D. Disputing (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 gazillion 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

Disputation involves teaching clients to, "recognize and dispute their irrational self-statements, as well as persuading them to do so vigorously and often..." (Ellis, Bernard, 2006) This is the core of REBT treatment. Disputation can require intuition and creativity on the part of the therapist, because irrational beliefs do not generally yield to logical arguments, especially earlier in treatment.

Perkins (2007) offers three disputation methods, referred to as putting irrational beliefs "on trial."

Empirical disputing shows that there is not sufficient evidence for the belief, and that there is sufficient evidence for alternative, functional beliefs.

Logical disputing helps the client discover that logic does not support the irrational belief. If offers alternative perspectives that are logical.

Pragmatic disputing helps the client assess whether the belief is contributing to the client's desired outcomes or being harmful. Self-defeating beliefs respond well to this form of disputation.

Disputation as Homework and Self Help

Disputation is given as homework, as addressed earlier. Below is a structure for this. It is adapted from various articles and materials.

1. Choose a behavior or feeling pattern that has a negative effect on your life.

2. Identify some irrational beliefs that support this pattern. Use the twelve irrational beliefs list shown earlier. Beginners should make sure that the belief is not easily defended in a rational way.

3. Identify one or more underlying thinking styles. Use the section on thinking styles provided earlier.

4. Write down as much evidence as you can showing that this belief is not realistic.

5. Write down any evidence you can find that the belief is true.

6. Write down the worst thing that would happen if your demand goes unmet or your expectation is violated, whether this means not getting what you want, or getting what you don't want.

7. Write down the good things that you might be able to cause to happen if you don't get your way.

Ellis suggests that clients use techniques that will help them make a habit of disputation. The client can hold out a reward that is contingent upon completing the exercise. If the client does not complete it, they can set the alarm clock half an your earlier, and commit to completing the exercise upon arising. (Perkins, 2007)

Ellis insists that clients should recite their functional beliefs with intensity in order to prevent the gains from slipping. (ibid; Ellis & Dryden, 2007)

Making a recording allows the client to increase their commitment to these new ways of thinking by listening to the recording and playing it for trusted friends, their therapist, or there REBT group. Using the recording as a baseline, the client can record the same beliefs with even more intensity, thus raising the bar. (Perkins, 2007)

Zig Zag Disputation

Another form of disputation is the zig zag technique. This is particularly useful when the client has at least begun to accept a rational belief. Ellis and Dryden (2007) describe using the technique in a group context.

The steps go as follows:

1) Write down a rational belief.

2) Rate the belief as to how heartfelt your acceptance of the belief is. Use a scale from one to 100.

3) Think of an argument against the rational belief.

4) Come up with an argument that rebuts that argument.

5) Continue until you run out of arguments against your rational belief.

6) Rate your conviction regarding the rational belief.

7) Compare the two before and after ratings. Usually, there will be a much higher rating for the rational belief at the end of this exercise.

Additional Examples

Discussing relapse risk helps clients to respond more appropriately to an recurrence of symptoms or irrational thinking patterns. This can include a discussion of ways to prevent relapse that bear some resemblance to a chemical dependence relapse prevention plan.

Behavioral assignments of various kinds can help the client carry treatment into daily life.

Supplementary strategies and techniques add to the clients ability to benefit from treatment. These can include skills such as relaxation training and interpersonal skills training.

Steps in a Typical REBT Session

Below are the steps as they might take place in a typical REBT session. The reader can see how much emphasis is placed on education and training.

1. Homework review helps the client address obstacles and receive reinforcement for follow through.

2. Targeting a problem gives in-session practice in working on irrational beliefs and behaviors with the support of the therapist.

3. Perform an ABC analysis on the problem. Including secondary symptoms helps the client gain depth and skill. Secondary symptoms are the reactions of the client to their irrational beliefs and resulting feelings. Look for any global self-judgment or anxious reactions.

4. Training and motivation are supported with the help of the therapist by focusing on any problem areas. This can include beliefs, skills, or determining how best to approach a new challenge. The therapist brings client attention to how their beliefs are affecting their emotional reactions and behavior. Negative outcomes must be highlighted in connection to these reactions. Outcomes in interpersonal relationships, work, health, and any other arena may be important and improve motivation.

5. Responses and beliefs of the client come into focus when coping with challenges. Work with the client to come up with constructive ways to respond to the activating event. This may involve disputation, devising better behaviors, or choosing self-help techniques to employ prior to, during, or after such events. Having the client envision how they would prefer to behave, feel, and think can function as goals to help in choosing these coping strategies as pathways to these goals. These goals should be short term early in treatment, and can be long term as the client gains more success and skill. Brainstorming is a good technique, and even ideas that are not constructive can become part of the therapy when they are analyzed in terms of client goals. A bad idea can help to highlight ways the client is still attached to irrational beliefs.

6. New functional beliefs and behaviors are identified for homework following the session. Plan with the client as to how they will mitigate potential problems.

Cognitive Techniques Any cognitive technique that supports the client's goals can be considered for REBT. REBT does not limit itself to cognitive methods, but they are most commonly used. Froggatt (2005) provides an annotated list, from which the following cognitive techniques are drawn.

Devil's Advocate: I'll take your position, and you argue against it. This gives the client practice in disputation. It also gives them a third-person perspective that will help them see the irrationality of their dysfunctional beliefs.

Put Catastrophic Thinking Into Perspective: On a scale of zero to 100, how bad is your current catastrophe? The client may choose a high rating. The therapist then asks where the client would place a variety of worse situations. The client realizes that they don't have much room at the top of the scale for these things. This helps the client question their catastrophizing.

Dispute a Double Standard: If the client is applying a harsh standard to themselves, would the apply it to others? If not, why? This calls into questioning the validity of harsh self-judgment. The opposite will also work, when the client is highly judgmental of others.

Reframing: How does this situation create an exciting challenge for you? This any other of the endless variety of reframes in the therapist's tool bag are fair game. The purpose is to get a useful shift in perspective.

Imagery: Imagine yourself in a very positive, resourceful state of mind with excellent posture, coping with this situation really effectively. REBT can incorporate imagery work.

Behavioral Techniques

The following are typical behavioral techniques used in REBT.

Risk-Taking involves taking action that provokes unrealistic fears, so that clients can desensitize themselves and confront irrational beliefs. An avoidant client can take on a challenge that involves risk of failure. A common example is to be involved in social situations and initiate conversations.

Paradoxical Behavior takes place when the client engages in behavior that is completely counter to their usual dysfunctional behavior in a situation. Clients are encouraged to do this, rather than to attempt to create the ideal behavior. This can reduce procrastination. It builds the client's sense of being dynamic and can produce a feeling of liberation.

Exposure Techniques can be real or imaginary. The client experiences something that they are afraid to experience. This may be done in steps that the client can tolerate and become accustomed to.

Shame Attacking reduces the client's intense reaction to or avoidance of shame. This is actually an exposure technique in which the client faces a shame-producing experience such as being in public with somewhat shabby clothes or whatever would produce disproportionate shame. While engaging in the behavior, the client notes and disputes irrational beliefs that come up. The therapist may accompany the client initially.

Postponing Gratification makes room in the client's life for functional behavior. It provides practice in disrupting automatic behavior. This may help the client do REBT homework or other constructive actions.

Treatment with REBT

Depression In working with depression, Ellis found patterns of dysfunctional belief that conformed to the core beliefs and underlying thinking styles already identified in REBT. He also found that the irrational beliefs took on a form unique to depression. He felt that the pattern was one of perfectionism in self-evaluation, intolerance of anyone being inconsiderate toward them, and an inability to tolerate being challenged or frustrated.

This results in a paradox that compounds depression. On one hand, the client is harshly self-denigrating. However, their expectations for perfection in themselves is implied in their self-denigration and in their intolerance of negative treatment by others. Ellis refers to this as a paradox of self-denigration and self-deification. (ibid) In highlighting the "implicit grandiosity" of this stance, he refers to depression-inducing core beliefs as "omnipotent insistences." (Ellis, 1990)

Ellis boiled this down to three core irrational beliefs that depressed people tend to hold, "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 believed that the demand for perfection in self and the world (the first and third beliefs) gave the strongest inclination to depression. He pointed to research on depressed subjects ratings of their own success as supportive of his perspective. He also felt that the mental effort involved in processing these beliefs contributed to depression. (Eysenck, 1992)

Initially, Ellis had difficulty treating depressed patients. He came to feel that discomfort anxiety, untreated, would regenerate the ego anxiety that had been treated. He felt that this was because of clients' high level of egocentricity leading to a more intense, dysfunctional reaction to any anxiety, even more situational anxiety. He found that REBT became much more effective with depressed patients when he shifted his focus of treatment to discomfort anxiety as soon as ego anxiety was mostly resolved. (Ellis, 1990)

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.

Families

According to Ellis, A., and Dryden W. (2007) Much of the emphasis in family work with REBT is on individual thought patterns as described in individual work. However, the nature of family disturbances and dynamics informs the treatment objectives and helps identify the irrational beliefs of family members. The resulting improvements allow the family members to be less reactive toward each other and more focused on achieving desirable outcomes in their relationships and in their contributions to the family. Families disturbances often result from its members having difficulty coping with a member with behavioral problems of some kind. REBT helps the more functional members establish more effective attitudes and behaviors for successfully coping with such members.

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.

Groups

Group work in REBT emphasizes teaching unconditional self acceptance in a group that is conducted in a "structured, educational manner" (Ellis, A., and Dryden W., 2007) The groups are typically done over eight weeks with the expectation that members will grasp the concept and make their first steps toward self acceptance in this time. The groups are structured to the point of having a lesson plan for each meeting. (ibid)

Sex Therapy

In sex therapy, REBT works to disabuse individuals of dysfunctional preconceptions about sexual norms. Clients are seen to experience impaired sexual pleasure, intimacy, and performance because of beliefs that interfere with their unique sexuality. (Ellis & Dryden, 2007) This results in shame and sexual reticence rather than acceptance of unique sexual preferences or arousal patterns, as well as some normal ones. For example, clients may feel that failure to achieve simultaneous orgasm is abnormal. Functional beliefs about sex facilitate discussion of effective coping and functional sexual expression.

Conclusion

REBT is an effective form of cognitive behavioral therapy that lends itself to eclectic practice, has the capacity to evolve with emerging knowledge, and provides valuable conceptual tools for clients and therapists alike. Albert Ellis, its developer, pioneered many ideas that continue to deliver a profound effect on cognitive behavioral therapies.



References

Aurelius, M., Meditations. (2004). Hays, G. (translator). Kessinger Publishing.

Aurelius, M., The Meditations. (1994). Long, G. (translator). Retrieved Feb. 9, 2009, from http://classics.mit.edu/Antoninus/meditations.html

Becker, A. E., Burwell, R. A., Herzog, D. B., Hamburg, P., Gilman, S. E. (2002). Eating behaviours and attitudes following prolonged exposure to television among ethnic Fijian adolescent girls. The British Journal of Psychiatry. 180: 509-514.

Balevre P. (2001). Professional nursing burnout and irrational thinking. Journal for Nurses in Staff Development. Sep-Oct;17(5):264-71.

Birley, A. R. (2000). Marcus Aurelius: a biography. Florence, KY: Routledge. 2nd ed., rev.

Bernard, M.E., Ellis, A., Terjesen, M. (2006). Rational-emotive behavioral approaches to childhood disorders: history, theory, practice and research in Ellis, A., Bernard, M. E, (Eds.). (2006). Rational-Emotive behavioral approaches to childhood disorders: theory, practice and research. Springer.

Cialdini, R. (2008) Influence: Science and Practice. Needham Heights, MA: Allyn & Bacon.

Copeland, M. E. (1997). Wellness recovery action plan. Brattleboro, VT: Peach Press.

David, D., Szentagotai, A., Eva, K. & Macavei, B. (2005). A synopsis of rational-emotive behavior therapy (REBT); fundamental and applied research. Journal of Rational-Emotive & Cognitive-Behavior Therapy.

Dickerson F. B., Lehman A. F. (2006). Evidence-based psychotherapy for schizophrenia. Journal of Nervous and Mental Disease. Jan;194(1):3-9.

Dryden. W. (2003). Rational emotive behaviour therapy: Theoretical developments (Advancing theory in therapy). New York: Brunner-Routledge.

Ellis, A. (2006a). Rational emotive behavior therapy and the mindfulness based stress reduction training of jon kabat-zinn. Journal of Rational-Emotive & Cognitive-Behavior Therapy. Mar 24(1) 63-78.

Ellis, A. (2006b). Ask Dr. Ellis, May, 2006. REBT Network. Retrieved, 2/12/2009 from http://www.rebtnetwork.org/ask/may06.html.

Ellis, A. (2005). Can rational-emotive behavior therapy (REBT) and acceptance and commitment therapy (ACT) resolve their differences and be integrated? Journal of Rational-Emotive & Cognitive-Behavior Therapy. Springer. Jun;23(2):153-168.

Ellis, A. (2003). Early theories and practices of rational emotive behavior theory and how they have been augmented and revised during the last three decades. Journal of Rational-Emotive & Cognitive-Behavior Therapy. 21(3/4).

Ellis A. (1994). The essence of rational emotive behavior therapy (REBT): a comprehensive approach to treatment. http://web.archive.org/web/19981206071447/http://rebt.org/essays/teorebta.html

Ellis, A. (1993). The nature of disturbed marital interaction. Paper presented at the Annual Convention of The American Psychological Association, Los Angeles, September 7, 1974. Revised, 1993.

http://web.archive.org/web/19990423170722/www.rebt.org/essays/tnodmi1.html

Ellis A. (1990). Discomfort anxiety: a new cognitive-behavioral construct. Reprinted from The Essential Albert Ellis (1990). Windy Dryden, (Ed.). New York: Springer Publishing Co., pp. 94-113. This chapter amalgamates two papers first published in Rational Living as Discomfort anxiety: A new cognitive-behavioral construct (parts I and 2), 14 (1979) and 15 (1980), respectively.

Ellis A., Abrams M. & Abrams L. (2008). Theories of personality. Thousand Oaks, CA: Sage Press.

Ellis, A., Dryden W. (2007). The practice of rational emotive behavior therapy. New York: Springer Publishing.

Ellis, A., Bernard, M. E, (Eds.). (2006). Rational-emotive behavioral approaches to childhood disorders: theory, practice and research. New York: Springer.

Eysenck, M. W. (1992). Anxiety: the cognitive perspective. New York: Psychology Press.

Feltham, C. (Ed.). (1997). Which psychotherapy?: Leading exponents explain their differences. Thousand Oaks, CA: Sage Publications.

Fenichel, M. (2002). Magnificant Journeys - A Conversation on Mind and Psychology with Aaron T. Beck and Albert Ellis, American Psychological Association, 110th Convention. Retrieved, 2/12/2009 from http://www.fenichel.com/Beck-Ellis2002.shtml.

Fenichel, M. (2000). New Concepts in Practice: On Therapy-- A Dialogue with Aaron T. Beck and Albert Ellis , American Psychological Association 108th Convention. Retrieved 2/12/2009 from http://www.fenichel.com/Beck-Ellis.shtml.

Froggatt, W. (2005). A brief introduction to rational emotive behaviour therapy, 3rd ed. Retrieved, 1/31/2009 from http://www.rational.org.nz/prof/docs/Intro-REBT.pdf

Harrington, N. (2006). Frustration intolerance beliefs: their relationship with depression, anxiety, and anger, in a clinical population. Cognitive Therapy and Research, 30, 699-709.

Joyce, M. R. (2006). A developmental rational-emotive behavioral approach for working with parents, in Ellis, A., Bernard, M. E, (Eds.). (2006). Rational-Emotive behavioral approaches to childhood disorders: theory, practice and research. New York: Springer.

Kaminer, D & Stein, D. J. (2004) An evolutionary perspective on obsessive-compulsive disorder. CNS Forum: Annual Reviews: OCD. Lundbeck Institute. Retrived, 2/12/2009 http://www.cnsforum.com/clinicalresources/articles/annualreviews/ocd_evolution/ Kaufman, M. (2007). Albert Ellis, 93, influential psychotherapist dies. New York Times, July 25.

Leichsenring F, Hiller W, Weissberg M, Leibing E. (2006). Cognitive-behavioral therapy and psychodynamic psychotherapy: techniques, efficacy, and indications. Am Joural of Psychotherapy. 60(3), 233-59.

Leichsenring F., Leibing E. (2003). The effectiveness of psychodynamic therapy and cognitive behavior therapy in the treatment of personality disorders: a meta-analysis. American Journal of Psychiatry. Jul;160(7), 1223-32.

Martin-Krumma, C. P., Sarrazinb, P. G., & Peterson, C. (2005).The moderating effects of explanatory style in physical education performance: a prospective study. Personality and Individual Differences, 38(7), 1645-1656.

Mersch, P. P. (1995). The treatment of social phobia: the differential effectiveness of exposure in vivo and an integration of exposure in vivo, rational emotive therapy and social skills training. Behavior Research and Therapy. Mar;33(3), 259-69.

Mikulincer M, Dolev T, Shaver P. R. (2004). Attachment-related strategies during thought suppression: ironic rebounds and vulnerable self-representations. Journal of Personal and Social Psychology. Dec;87(6), 940-56.

Mikulincer M, Shaver, P. R. (2001). Attachment theory and intergroup bias: evidence that priming the secure base schema attenuates negative reactions to out-groups. Journal of Personal and Social Psychology. Jul;81(1), 97-115.

M?ller A. T., Botha H. C. (1996). Effects of a group rational-emotive behavior therapy program on the Type A behavior pattern. Psychological Reports, Jun;78(3 Pt 1), 947-61.

M?ller A. T., Kotz? HF, Sieberhagen KJ (1993). Comparison of the effects of auditory subliminal stimulation and rational-emotive therapy, separately and combined, on self-concept. Psychololgical Reports, Feb;72(1), 131-45.

Perkins, M. (undated). Disputing irrational beliefs. The Internet Guide to Rational-Emotive Behavioral Therapy and Cognitive Behavior Therapy. Retrieved 9/23/2007 from http://www.rebt-cbt.net/My_Homepage_Files/Page7.html.

REBT Institute. (2009). REBT Moves Forward. Retrieved 2/12/2009 from http://www.rebtnetwork.org/library/REBT_Moves_Forward.html.

Shapiro, F. (2001). Eye movement desensitization and reprocessing (EMDR): basic principles, protocols, and procedures. (2nd ed.) New York: The Guilford Press.

Southwick SM, Vythilingam M, Charney DS. (2005). The psychobiology of depression and resilience to stress: implications for prevention and treatment. Annual Review of Clinical Psychology,1, 255-91.

Sutton-Simon, K. (1979). A study of irrational ideas of individuals with fears of heights, with social anxiety, and with fear of heights plus social anxieties. Cognitive Therapy and Research, 3(2), 193-204.

Turkington, D., Kingdon, D., Weiden, P. J. (2006). Cognitive behavior therapy for schizophrenia. American Journal of Psychiatry. 163:365-373, March 2006.

Vernon, A., Bernard, M. E. (2006). Applications of REBT in schools: prevention, promotion, intervention in Bernard, Ellis, A., Bernard, M. E, (Eds.). (2006). Rational-Emotive behavioral approaches to childhood disorders: theory, practice and research. New York: Springer.

Wessler, R. L. (1996). Idiosyncratic definitions and unsupported hypotheses: Rational emotive behavior therapy as pseudoscience. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 14(1),

Yourell, R. (2006). ABC Client Handout. Psych Innovations.

CLOSE [X]

CLOSE [X]

CLOSE [X]