& The Practical Therapist Series’Rational Emotive Behavior TherapyPublisher's Note This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold with the understanding that the publisher is not engaged in rendering psychological, medical, or other Books in The Practical Therapist Series® present authoritative answers to the question, “What-do-I-do-now-and-how-do-I-do-it?” in the practice of psychotherapy, bringing the wisdom and experience of expert mentors to the practicing therapist..A book, however, is no substitute for thorough professional training and adherence to ethical and legal standards. At minimum: = The practitioner must be qualified to practice psychotherapy. = Clients participate in psychotherapy only with informed consent. = The practitioner must not Guarantee” a specific outcome. — Robert E. Alberti, Ph.D., Publisher Other Titles in The Practical Therapist Series® Creative Therapy with Children and Adolescents Integrative Brief Therapy Meditative Therapy Metaphor in Psychotherapy>, “~~ Rational Emotive Behavior Therapy A Therapist’s Guide Albert Ellis, Ph.D. Catharine MacLaren, M.S.W. The Practical Therapist Series’ Impact & Publishers’ ATASCADERO, CALIFORNIACopyright ©1998 by Albert Ellis Institute Fourth Printing, January 2003 Alll rights reserved under international and Pan-American Copyright Conventions. No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, digital, electronic, mechanical, photocopying, recording or otherwise, without express written permission of the author or publisher, except for brief quotations in critical reviews. Impact Publishers and colophon are registered trademarks of Impact Publishers, Inc, ATTENTION ORGANIZATIONS AND CORPORATIONS: This book is available at quantity discounts on bulk purchases for educational, business, or sales promotional use, For further information, please contact Impact Publishers, P.O, Box 6016, Atascadero, CA 93423-6016 (Phone; 1-800-246-7228). Library of Congress Cataloging-in-Publication Data Ellis, Albert. Rational emotive behavior therapy : a therapist’s guide / Albert Ellis and 7 MacLaren. Pp -- (The practical therapist series) Includes bibliographical references and index. ISBN 1--886230-12-9 (alk. paper) 1, Rational-emotive psychotherapy. I. MacLaren, Catharine. U1, Title, TH, Series. RC489.R3E464 1998 616,8714-DC21 98.7505 cr Cover design by Sharon Schnare, San Luis Obispo, California Printed in the United States of America on acid-free paper Published by Impact «2 &% Pubils POST OFFICE BOX 6016 ATASCADERO,CALIFORNIA 83423-6016 ‘www impactpublishers,comDedication Dedicated to Janet L. Wolfe — Albert Ellis Dedicated to Elizabeth M. Love-Brockway and my parents — Catharine MacLarenContents Introduction 1 Rational Emotive Behavior Therapy: An Introduction and a Reflection 2 The Philosophic and Personality Theory Foundations of REBT 3 The REBT Theory of Personality Disturbance and Change The Process of Assessment in REBT Cognitive Techniques in REBT Emotive/Experiential Techniques in REBT Behavioral Techniques in REBT SN A A A The Integration of REBT with Other Systems of Therapy Summary Appendix A: How to Maintain and Enhance Your Rational Emotive Therapy Gains Appendix B: References/Resources Index 13 25 57 75 91 107 121 123 135 163Introduction |A Therapist’s Guide is to present you, the mental health professional, with a comprehensive look at Rational Emotive Behavior Therapy (REBT) in an easy-to-read format. The first portion of the book focuses on answering the questions: How, when, and where did REBT originate? We discuss the philosophically based origins of the theory as well as the core reasons that people become disturbed and stay disturbable. We have then devoted several chapters to the actual hands-on practice of REBT. We begin with a discussion of the assessment phase of therapy and then describe the variety of specific cognitive, emotive, and behavioral interventions commonly used in this approach. We have also included numerous case examples in order to facilitate your learning process. Finally, we have included a chapter on integrating REBT with a range of other theoretical frameworks. Whether you are a newcomer to the field or a seasoned professional, we hope that you enjoy this book and use it as a reference guide in the future. (): primary goal with Rational Emotive Behavior Therapy: 1Rational Emotive Behavior Theory: An Introduction and a Reflection ational Emotive Behavior Therapy is based on the R ssn that cognition, emotion, and behavior are ot disparate human functions but are, instead, intrinsically integrated and holistic. When we feel, we think and act; when we act, we feel and think; and when we think, we feel and act. Why? Because humans rarely, except for a few moments at a time, just feel, or just think, or just behave. When people are disturbed, they think-feel-act in a dysfunctional, self-defeating manner and when they undisturb themselves they almost invariably change some of their cognitions, change their emotional reactions, and change their activities. Susan, one of AE’s* clients, was panicked about talking to attractive men and therefore avoided them at dances, social, and other gatherings. She perceived them as “dangerous,” felt severe anxiety when she encountered them, and bolted away from them when it looked like they might approach her. She thought them “dangerous,” felt panic, and acted avoidantly. After several sessions of REBT Susan mainly realized that she was telling herself that she absolutely must not be rejected by * Throughout the book the authors arc identified by thcir initials: “AE” = Albert Ellis; SCM” = Catharine MacLaren.4 Rational Emotive Behavior Therapy attractive men or else she was a reject and a worthless person. She changed her core Irrational Beliefs to, “I prefér to avoid rejection by attractive men but if I am rejected that merely proves that I failed this time, can learn from my rejection, and can perhaps do better next time. But even if I always fail with them, I’m merely frustrated and handicapped in one important area of my life and can enjoy relationships with less attractive men.” As noted in the theory of REBT, Susan changed one of her core negative cognitions, and thereby helped herself reduce her panic and avoidance. That sounds good, and supposedly “proves” that her changing her Irrational Beliefs made Susan less anxious and phobic. Actually, Susan changed her core Beliefs, all right, but she also, whether she realized it or not, changed several other perceptions and cognitions, such as: 1) Attractive men are “dangerous.” 2) Rejection by them is “horrible.” 3) “Unless one really favors me, I can’t be happy at all.” 4) “Every time I risk it and fail with one, that makes me a totally worthless individual.” 5) “If I settle for a less attractive man, people will see I weakly gave in and will consider me a loser.” So Susan’s main cognitions were complex and led to other negative cognitions — which, in turn, tended to change when she changed one or two of her Irrational Beliefs. Moreover, Susan’s feelings changed from panic to concern — a healthy negative feeling that allowed her thereafter to converse with attractive men and only feel sorry and disappointed if they rejected her. With her new Rational Beliefs, she fe/t comfortable on seeing attractive men approach her, at times she actually fet happy to sce them approach, she fé/t like staying and talking to them, she felt interested and absorbed when she conversed with them, and she had various related feelings. As for her actions, when she stopped believing that she absolutely must not be rejected by attractive men, and that she was‘An Introduction and a Reflection 5 a worthless person if they rejected her, she soon took several actions along with stopping her phobia about them. 1) She looked, often, for attractive men, instead of looking away from them. 2) She actually approached some of them herself. 3) She arranged for some introductions to them. 4) She talked animatedly to them. 5) She tried to get some of them to date her. Et cetera. ‘Moral: According to REBT, disturbed and less disturbed thoughts, feelings, and actions are complicated, varied, and significantly affect each other. The REBT perspective remains as AE described it over forty years ago: Instead, then, of saying, ‘Jones thinks about this puzzle,” we should more accurately say, “Jones perceives-moves-feels- thinks about this puzzle.” Because, however, Jones’ activity in reaction to the puzzle may be /argely focused upon solving it and only incidentally on seeing, manipulating, and feeling about it, we may perhaps justifiably emphasize only his thinking. Emotion is not one thing but a combination and holistic integration of several seemingly diverse, yet actually closely related, phenomena (Ellis, 1958, p. 35). Iniegative and Eclectic Aspects of ‘REBT In REBT’s therapeutic endeavor to help people change their Irrational Beliefs to Rational Beliefs and thus improve their emotional and behavioral functions, it is always integrative. REBT uses many multimodal methods (Lazarus 1989) — cognitive, emotive, and behavioral. But it integrates them and helps clients to see how they importantly affect each other. REBT has a number of unique theories, as we shall show in later chapters, it bases its practice on its theory, and is not merely “eclectic.” Its theory also incorporates significant parts of other therapeutic systems. Thus, it reveals clients’ unconscious motives6 Rational Emotive Behavior Therapy and defense systems, as Freudians do. It uses Jung’s concept of self-actualization. It includes Rogers’ theory and practice of unconditional positive regard or fall acceptance. It energetically encourages clients to change, as Adlerians do. It actively-directively gives homework assignments, uses operant conditioning, and employs in vivo desensitization as Skinnerians and other behaviorists do. It uses many experiential, encounter, and feeling methods, as Gestalt therapists do. At times, though rarely, it even uses irrational and magical techniques, when clients are “allergic” to rational ones. REBT integrates some aspects of many therapeutic theories, and eclectically uses specific techniques from many sources for individual clients who may not follow its favorite methods. Further discussion of integrating REBT with other approaches can be found in chapter 8. The Effectiveness of REBT. AE originated REBT because it was more effective than other forms of therapy. In the first major article on it (Ellis, 1958, p. 49), he predicted “psychotherapy which includes a high dosage of rational analysis... will prove to be more effective with more types of clients than any of the non-rational or semi-rational therapies now being widely employed.” Forty years of research on psychotherapy has shown that prediction to be partly substantiated by hundreds of studies of REBT and CBT. But only partly! First of all, AE’s theory that people have both Rational Beliefs (RBs) and Irrational Beliefs (IBs) and that when they have frequent and intense IBs they tend to be more disturbed than when they hold fewer and weaker IBs, has been backed by considerable evidence. Well over a thousand published studies have backed this hypothesis (Clark, 1997; Glass & Arnkoff, 1997; Schwartz, 1997). According to these studies, people’sAn Introduction and a Refiection ve acknowledged IBs and their degree of emotional disturbance seem to be significantly correlated. Thus, one of the major hypotheses of REBT has much evidence to back it. AE’s second major theory — that when people change their IB’s to more Rational Beliefs, either in therapy or by self-help procedures, they become significantly less disturbed — also has a great deal of confirming evidence behind it. Over 250 controlled studies of the effectiveness of REBT have been published, and the great majority of them show positive results (McGovern & Silverman, 1984; Lyons & Woods, 1991; Silverman, McCarthy & McGovern, 1991). More than a thousand studies have been published on the efficacy of various kinds of cognitive behavioral therapy (CBT), and again the great majority of them show it to be effective (Dobson, 1989; Hollon & Beck, 1994). No other form of psychotherapy except behavior therapy has produced such good experimental results, and today behavior therapy usually includes many cognitive methods. REBT and CBT, as can be seen, have excellent experimental findings and have been shown to be widely effective with a large variety of clients. More and more aspects of them are now being “snuck in” to many other therapy systems! The Origins of REBT The origin of rational emotive behavior therapy goes back to 1953, when AE abandoned psychoanalysis. Thad practiced analysis for six years, but I found it to be quite inefficient. At best, I helped my clients to see some of the psychodynamic aspects of their disturbances, but not how to change their thinking, their emoting, and their behaving so they could undo the self-defeating aspects of their lives, Presumably, they understood how8 Rational Emotive Behavior Therapy they got the ways they were — but not what to do to change. Thus, one client gained insight into the fact that he unconsciously hated his father and that he had “transferred” that feeling into hating his boss and other males who had traits similar to his parent; but he was not at all successful at giving up his self-sabotaging actions toward his wealthy and dominating father nor his powerful and dictatorial boss. His dramatic “insight” into his problems with strong men and his gush of feelings when this occurred helped him very little. This and several other cases, where insight and expression of repressed feelings just didn’t work, “set me to do some tall thinking about psychotherapy.” First, I went back to my prepsychoanalytic techniques of therapy, particularly those I had learned in sex and marital therapy, and started giving my clients activity homework assignments and skill training. That worked much better, particularly with socially phobic clients, who had considerable insight into the supposed origins of their inhibitions but who still refused to use this insight to relate to others. Within a few weeks of in vivo desensitization and relationship training, they made more progress than they had in a year or more of psychoanalysis. Interesting! So I kept slipping behavioral methods into my analytic therapy. Even more valuable to my therapeutic approach was my revision of the whole concept of insight. I began to see that giving clients insight into the past helped a few clients see that, however badly they were treated as children, they still did not have to react in the same immature way today. So they forgave their parents and‘An Introduction and a Reflection went on with their lives. But the great majority who had the same dramatic insights hardly improved at all. They still hated their parents and themselves. No, the more traditional concept of insight is not enough for deep and lasting personal change. The reality is that most of us are very good at identifying the wrongs which we have experienced during our lifetimes but that knowledge, in and of itself, rarely produces lasting and positive change. In fact, without appropriate steps to reconcile and move on from those negative experiences, it can often result in extremely unhelpful self-pity and have a “retraumatizing” effect on some individuals. I thought about this, and realized that the kind of insight that clients usually gain in most forms of therapy isn’t very helpful. It doesn’t show them what they are now doing to keep alive the hurts and horrors of the past — or, for that matter, what they did then, during their childhood, to make themselves hurt and horrified. Why did they get so upset in the first place? What were they now doing to retain, or even worsen, this upsetness? What about insight into that? I had always been interested in philosophy, especially the philosophy of human happiness, and made it one of my own hobbies from the age of sixteen onward. So I re-read many of the ancient and modern philosophers to help me come up with answers to these important questions. Fortunately, they did help. For many philosophers — especially the ancient Asians, Gautama Buddha and Lao-Tsu and the ancient Greeks and Romans Epicurus, Epictetus, and Marcus Aurelius — had clearly seen what the psychoanalysts and the behaviorists neglected: that humans are constructivistsRational Emotive Behavior Therapy who don’t merely get disturbed by external influences but also significantly contribute to and maintain their own dysfunctional thinking, feelings, and doings. As Epictetus nicely put it two thousand years ago, “People are disturbed not by things but by the views they take of them!” Phenomenalism, constructivism, and postmodernism! I am happy to say that in the 1950’s I managed to bring Epictetus out of near-obscurity and make him famous all over again. The Hi: of REBT Sparked by philosophy, I worked on my psychothera- peutic theory from 1953 to 1955, and finally came up with what I first called Rational Therapy (RT) in January 1955 (Ellis 1957a, 1957b, 1958). In it, I presented the rather unique ABC theory of emotional disturbance. This held that when people were confronted with Adversity (A) and reacted with disturbed Consequences (C), such as severe anxiety and depression, it was largely their Belief System (B), together with A, that led to their dysfunctions. Thus, A x B=C. This theory significantly differed from psychoanalytic, conditioning, and other popular theories of emotional disturbance that were popular in 1955. Now cognitive conceptions of psychotherapy were not entirely new, and were espoused by Pierre Janet (1898), Paul Dubois (1902), Alfred Adler (1929), and other therapists in the early twentieth century. But in the 1950's they were quite unpopular, having been overwhelmed by psychodynamic and, to a lesser degree, conditioning ideas. So when I heavily emphasized B (Beliefs) in the ABC’s of Rational Therapy, I at first had‘An Introduction and a Reflection 11 few followers. Using my own Belief System to bolster me, however — and particularly convincing myself that I didn’t have to have the approval of other therapists, though it would be nice to have it —I persisted in promulgating REBT as a pioneering form of cognitive-behavioral therapy (CBT) in spite of almost universal opposition. I wrote and lectured extensively on the subject until, in the 1960’s, several capable practitioners followed me with their own versions of CBT — including Glasser (1965), Beck (1976), Bandura (1997), and Meichenbaum (1977). My innovations in therapy not only put a high premium on the use of cognition but also for the first time welded it with behavior therapy, so that RT became the first of the major cognitive behavior therapies, This was because I used some of the behavioral techniques of John B. Watson (Watson, 1919) to conquer my own public speaking phobia and my own social anxiety when I was 19 years old. Also, before I became a psychoanalyst, I used behavioral methods in sex therapy and general psychotherapy. When I stopped calling myself a psychoanalyst in 1953, I started using these behavioral methods more, and I incorporated them into Rational Therapy when I began to do it in 1955 and became a pioneering cognitive behavior therapist. As I said in my first major paper on it, at the American Psychological Association Convention in Chicago on August 31, 1956, Rational Therapy was also highly active-directive, confrontational, and emotive. But, because of its title, therapists often failed to acknowledge its emotional aspects. In 1961, I and Robert Harper, who was my leading collaborator,Rational Emotive Behavior Therapy changed its name to Rational-Emotive Therapy (RET). Raymond Corsini rightly objected to this designation for over twenty years, as he said that RET had a very strong behavioral aspect and therefore should preferably be called Rational Emotive Behavior Therapy. I wrongly argued with Ray, because RET became very popular in the 1960’s, but I finally admitted that he was right and I was wrong. So in 1993 I formally changed the name to Rational Emotive Behavior Therapy (Ellis, 1993), which I think will be its final designation. It describes, in a fairly precise manner, the kind of comprehensive, integrative, and multimodal system that it actually is.The Philosophic and Personality Theory Foundations of REBT EBT has, at its foundation, two kinds of theories. First, its philosophical outlook and its general theory ofhuman ersonality and its disturbance. Second, its theories of therapeutic change. These sets of theories integrate with each other in some important respects. In this chapter we will mainly consider REBT’s philosophic outlook and the questions of personality and why some people seem to be more disturbed than are others. Postmodern Philosophy and REBT AE originated REBT as a logical positivist — one who believed that truth was not absolute or pure but that as scientists we come close to it by finding the facts of a situation and then drawing conclusions from these facts. Truth was indeed only temporary because, as Karl Popper (1985) showed, even when a hypothesis is backed up by a good deal of evidence later factual discoveries may falsify it. Logical positivism has its limitations, as has been shown by Popper (1985), Bartley (1984), and Mahoney (1991), and has been especially shown to be shaky by several postmodernist 13 >, Xd14 Rational Emotive Behavior Therapy thinkers (Derrida, 1976; Feyerband, 1975; Gergen, 1995). They point out that “facts” and “truths” are always identified by people and therefore seem to have no “objective” or “true” reality. For many years something of a phenomenologist and existentialist, AE has also become a moderate, not a radical, postmodernist. REBT always was fairly postmodern, because it is notably against absolute musts and shoulds, and therefore opposed to the notion of absolute truth. Its main postmodern ideas are these, as outlined in, “Postmodern ethics for active-directive counseling and psychotherapy” (Ellis, 1997). 1) Perhaps some kind of indubitable objective reality or thing in itself exists, but we only seem to know it through our fallible, personal-social, different and changing human perceptions. We do not have any absolute certainty about what reality is or what it will be — despite our being often strongly convinced that we do. 2) Our views of what is good or bad, what is right and wrong, what is moral and immoral are, as George Kelly (1955) pointed out, largely personal-social constructions. The identification of universal truths is an impossible task and all ethical beliefs have a constructive nature. 3) Although human personality has some important innate and fairly fixed elements, it also largely arises from relational and social influences and is much less individualistic than is commonly thought. 4) People are importantly influenced or conditioned by their cultural rearing. Their behaviors are amazingly multicultural and there is no conclusive evidence that their diverse cultures are right or wrong, better orPhilosophic & Personality Theory Foundations 15 worse than others (Ivey & Ragazio-DiGilio, 1991; Sampson, 1990). Either/or concepts of goodness and badness often exist and are rigidly held, but they tend to be inaccurate, limited, and prejudiced. More open-minded perceptions of humans tend to show that things and processes exist on a both/and and an and/also basis. Because monolithic, either/or, all/none solutions to problems have their limitations, we had better consider a range of alternate, and/also solutions and test them out to see how well — and how badly — they work. 5) Just about all solutions we strive to achieve for our problems depend on choosing our goals and purposes from which to work. These are always arguable, never absolute. We can arrive at a consensus as to what goals and purposes to choose but not at any absolute agreement as to which are better and worse. REBT has sometimes been seen as nonconstructionist (Guidano, 1991; Mahoney, 1991), but it actually is unusually constructionist. It emphasizes people thinking and working in a flexible and adaptive manner. It holds that rigid, absolutistic musts by which people often upset themselves are learned from their culture but are also created by their own creative and biological tendencies. It helps clients to see how they create core dysfunctional philosophies and how they can constructively change them by thinking, by thinking about their thinking, and by thinking about thinking about their thinking (Dryden, 1995; Ellis, 1994, 1996; Ellis & Dryden, 1975; Ellis, Gordon, Neenan, & Palmer, 1998). In dealing with problems of self-worth it agrees with the constructionist and existentialist position of Heidegger (1962), Tillich (1953), and Rogers (1961) that humans can16 Rational Emotive Behavior Therapy define themselves as worthy just because they choose to do so. It deals with unconscious and tacit processes that create disturbance and abet problem solving. It holds that people have considerable natural ability to reconstruct and change themselves but it actively-directively tries to help them to do so in collaboration with an involved therapist. It emphasizes the use of the flexible, nondogmatic method of scientific hypothesizing and checking on hypotheses and the empirical exploration of values and standards to see what results they tend to produce. Philosophical Emphasis of REBT As noted above, much of the theory of REBT was derived from philosophy rather than psychology. As also noted, REBT is cognitive, emotive, and behavioral, and is not by any means strictly “intellectual.” But in some ways it favors clients making profound philosophical changes instead of only disputing their specific Irrational Beliefs and automatic negative thoughts and coming up with more sensible ones. Nor does it favor what is called “positive thinking,” or the replacing of negative thoughts with optimistic ones that sometimes are pollyannaish. Donald, for example, irrationally believed that he was a bad person because he had cheated his brother, David, out of part of the money their mother had left them in her will. Donald was executor of the will and illegitimately deducted several extra thousands of dollars for expenses in settling the estate and David naively accepted this. So Donald considered himself, a year later, a “rotten thief,” and was ashamed to tell David what he had done. He beat himself mercilessly and got depressed. Donald saw a hypnotist for several sessions who used positive thinking to help Donald see that he had done many good things, including helping David, for most of his life, but only a few bad things, such as cheating David. His positive thinking mantra,Philosophic & Personality Theory Foundations, 17 which he was to repeat strongly to himself many times, was, “I do many more good than bad deeds, therefore I am a basically good person.” This positive thinking worked for a while, but then Donald soon got very guilty and depressed again, and became quite disillusioned with the efficacy of his positive thought. When he came to see AE for REBT, he still held the covered up Irrational Belief, “I absolutely must not do any distinctly bad deeds. The good acts I do hardly erase the bad ones, which are never permissible. A really bad act, such as I did when cheating David, makes me a rotten person! I therefore deserve to suffer and be depressed. Only enough suffering will make me a good person. I’m really rotten to the core!” Donald’s positive thinking only shunted aside his demand that he never do bad deeds and for awhile covered up his negative, self-downing thinking — but it did not remove it. With REBT, AE helped him actively dispute his Irrational Beliefs and truly give them up. As a result of his doing so, together with doing some REBT “shame-attacking exercises” (explained on page 94) and forcing himself to honestly tell David what he had done, Donald began to see and work at adopting several core philosophies: 1) “There is no reason why I absolutely must not do any real bad deeds, though it is Highly preferable that I not do them.” 2) “I will always bea fallible human who, alas, will sometimes act poorly. Too bad, but I will do my best to behave /ss fallibly, rather than #fallibly.” 3) “Doing a bad act cannot make me, globally, a bad person, only a person who does some evil things, and had better try to correct them.” When, by strongly disputing and acting against his Irrational Beliefs, and thereby arriving at some core Rational Beliefs, (what REBT calls profound Effective New Philosophies), Donald truly undermined (not covered up) his disturbed thinking-feeling-18 Rational Emotive Behavior Therapy behaving. He was then able to become less depressed and less depressive. He got better rather than, with the positive thinking, merely felt better (which we explain in more detail in the next section). So we strive, in using REBT, to help people make a profound philosophical change — fundamentally changing their outlook and keeping it changed. This seems to go beyond changing their automatic negative thoughts to changing their core Irrational Beliefs. Doing so is a deeper form of thinking that we shall turn to again. Multicultural. ‘REBT REBT is unusually open to clients who come from different cultures and from minority groups within the same culture. This is largely because its central theory opposes absolutistic, rigid thinking but encourages individuals and groups to have innumerable preferences, goals, desires, and standards — as long as they do not dogmatically and dictatorially insist that they and others absolutely must follow them. If clients have inclinations that are significantly different from the standards of their family, culture, religious, or political group, but they do not break the law or harm others with these standards, REBT rarely discourages them. REBT clearly points out, however, that when they hold their goals and values in self-dictatorial or other-dictatorial ways, they will often get into individual and social trouble. Therefore, it would usually be best if they kept their personal and cultural rules, but held them as strong preferences instead of grandiose musts or commands. Therapists who use REBT theories and practices are therefore free to help different clients to achieve their own goals and values but to refrain from taking them to “musturbatory” extremes. Extremism and rigidity will often sabotage their personal and social purposes. Flexible, but still definite, standards usually willPhilosophic & Personality Theory Foundations 19 not. REBT practitioners therefore are able to fully accept — not blamefully condemn — clients from widely differing backgrounds, cultures, and religious orientations. How Does REBT Define Rational and Irrational? To some people, rational is a “bad word.” It means many things to different people — some of which are not very rational! As used in REBT, rational does not mean unemotional. Occasionally, we hear from clients who are new to REBT: “It seems as if you don’t want me to feel anything. Do you want me to go through life as an unemotional zombie?” Not at all! Rational people often had better be highly emotional — such as distinctly sorry, disappointed, and annoyed when things go wrong in their lives. As Windy Dryden has said, rational when used in REBT means “that which helps people to achieve their basic goals and purposes, whereas ‘irrational’ means that which prevents them from achieving these goals and purposes” (Dryden, 1984, p. 238). Otherwise put, rational means self-helping and irrational means self-defeating. However, because your clients choose to live ina social group, rational also means helping the group to survive and to achieve its basic goals, and irrational means seriously interfering with the group’s survival and well-being. Also, to be rational usually means being efficient in achieving one’s individual and community goals, but efficiency and rationality are not the same: since one can efficiently bring about self-defeating and social-defeating ends. Rational, again, is a word that has many meanings, some of them contradictory. From your clients’ view it normally means self-helping — getting more of what they want and less of what they don’t want. It is largely individualistic. But clients can choose to put social interests above their self-interest—and to some degree, as Adler (1929) showed, that és mental health as well as20 Rational Emotive Behavior Therapy community health. But even individualistic clients want to be accepted by others and are likely to be miserable when they are not. So individual mental adjustment overlaps with treating others nicely and properly. For both the individual’s and society’s sake it would seem rational to strike a balance between self-interest and social-interest — which is not easy! As postmodernists and constructionists, we can have no absolute, essential view of rationality, just as we can have no “true” view of what is “good” or “moral.” People can agree on “rational” goals, but hardly always do. Assuming that your clients wish to be less panicked, depressed, and enraged, you can help them to achieve this wish by using various REBT (and other therapeutic) methods. We therefore refer to these self-helping techniques as “rational.” Most of the time they will work better than other methods. But that does not mean that under all conditions and at all times with all clients they are “rational” or “good.” You can always be skeptical of their absoluteness and universality. Use them because you think they often or usually work. But remain open-minded and skeptical! Healelyy and Unhealthy Negative Feelings in REBT. REBT has several theories regarding healthy and unhealthy negative feelings when clients are faced with Adversities in their lives. First, it holds that virtually all feelings are “natural” and almost automatically follow after thoughts of or actual experiences of stimuli that the client views as obnoxious or unpleasant. This in itself is a “healthy” human reaction, because if people did not have healthy negative feelings, they would not try to reduce or avoid negative stimuli and would live miserable lives and often fail to survive. Positive feelings also motivate people to survive and to be productive.Philosophic & Personality Theory Foundations 21 So REBT encourages people to feel, and often feel strongly, in positive and negative ways. It is not, as some therapists wrongly believe, “rational” in a sense of favoring lack of passion, stoicism, or unfeelingness. It is more Epicurean than Stoic. REBT clearly distinguishes, however, when things go amiss, between healthy negative feclings — such as sorrow, regret, frustration, and annoyance — and unhealthy negative feelings — such as panic, depression, rage, and self-pity. Healthy negative feelings tend to produce self-helping and community-helping actions; unhealthy negative ones tend to interfere with reparative acts, or to result in inaction or destructive behavior. Thus, if one is concerned about failing a test, one studies harder to pass it. But if one is panicked about the possibility of failing it, one often avoids studying (which leads to more panic), studies anxiously and inefficiently, or doesn’t take the test. So REBT encourages your clients to feel strongly about succeeding at important tasks and relationships, but not to fall into the human propensity to raise their strong desires to absolutistic demands — “I must succeed or else I am worthless!” These produce dysfunctional negative feelings, especially panic and depression, that block their desires. The REBT theories of desires and preferences, on the one hand, and musts and demands on the other hand, says that these personal tendencies are intrinsically related, and that virtually all humans have both of them. We all have — for innate, biological reasons as well as from family and cultural upbringing — varying strengths of desire — mild, moderate, and strong. When people have strong desires, says REBT theory, they have (statistically) a greater tendency to make them into insistences and imperatives, Thus, your clients may moderately prefer that other people like them, and have little difficulty when some seem to dislike them. But if they strongly prefer approval,22 Rational Emotive Behavior Therapy they are much more likely to insist, consciously and/or unconsciously, “People must like me! If some don’t it’s awfisl and shows that I am not a likeable person!” Why people frequently turn their strong preferences and dislikes into internal commands is not entirely clear. Perhaps doing so helped them survive in primitive days when their social and physical environments were more dangerous. Biology and Human Rationality and Irrationality REBT, unlike other psychotherapies that teach that human disturbance is primarily learned or conditioned, hypothesizes that people innately and by social teaching develop into rational and irrational thinkers. Obviously, they have to be largely rational and self-helping or they would not survive. They are born constructivists, so that when they face problems and any adversity that they consider against their best interests — especially that of not surviving — they are creative problem-solvers. That is their nature, from early childhood onward, just as it seems to be the nature of other living creatures, except more so. First, humans are more creative and inventive about what to think, feel, and do to survive. Second, they have a wider range of pleasurable activities — games, sports, art, music, science, etc. —that are not necessary for survival, though they seem to help. Third, they are more practical and self-actualizing than the other animals. It is easy to emphasize human constructivism and to play down human destructivism. Defensively, we may not want to admit that we are often — damned often — irrational, self-defeating, socially immoral, and otherwise destructive of ourselves and others. As AE noted in a paper, “The Biological Basis of Human Irrationality” (Ellis, 1976), we cannot clearly prove that people are born, as well as reared, to be irrational, but there is a great deal of evidence to back this hypothesis. Witness:Philosophic & Personality Theory Foundations 23 1) Virtually all people sabotage themselves, and others, in many ways, despite their efforts and desires to do better. 2) Although cultural groups have widely different goals and values, their members easily add disturbance- creating irrationalities (absolute musts and demands) about their rules and standards. They thereby upset themselves. 3) Many human self-defeating behaviors exist — such as lack of discipline and procrastination — despite the self-helping teachings of people’s parents, peers, and the mass media. 4) People who vigorously oppose “foolish” behaviors often engage in them. Agnostics exhibit absolutistic philosophies and highly religious individuals act immorally. 5) Millions of people acknowledge their self-harming behaviors, such as excessive drinking and drugging, yet consistently indulge in them. 6) Many individuals fall back to destructive acts, such as aggression and gambling, that they have worked hard to overcome. 7) People often find it easier to perform self-destructive acts, such as overeating, than to sensibly stop them. 8) Psychotherapists, who presumably know best what is destructive behavior, frequently engage in it. So we see that virtually all people are born as well as raised to often be irrational, and that they easily disturb themselves. Fortunately, people are also largely rational; and they have a24 Rational Emotive Behavior Therapy unique human quality of being able (through well developed language) to think about their irrational thinking, and to think about thinking about their thinking. So they are still constructivist. You would do well to relieve many of your clients from self-damning by letting them know that, as humans will: they often easily think, feel, and act defeatingly, they can constructively change themselves, and. they require much work and practice to use their natural creativity to reduce their natural self-sabotaging.The REBT Theory of Personality Disturbance and Change EBT has several specific theories of how people become disturbed and what can be done to reduce or eliminate eir disturbance. These theories overlap with other main theories of psychological disturbance but in some respects they are different. Here are some of their important differences. Why and How People Become Psychologically Disturbed Psychological disturbance is varied and complicated and is by no means fully understood. It arises from people’s biological tendencies to be constructivist (self-helping) and destructivist (self-defeating) and the interaction of these tendencies with environmental conditions and social learning. People become disturbed in many different ways and partly because of many different conditions. We may well discover some, but not all, of the main reasons for their disturbances. Especially in the case of a specific individual, we may again discover some of the main “causes,” but not all the “causes,” for her or his emotional and behavioral problems. REBT hypothesizes that people are disturbed cognitively, emotionally, and behaviorally — yes, in all three ways — and that 25 <2 “~26 Rational Emotive Behavior Therapy we had better designate them as being cognitively-emotionally- behaviorally self-defeating and other-defeating, because they interactionally make themselves upset. They may primarily (but not only) have thinking, emotional, or behavioral problems, but they also have aspects of the other two modes of disturbance. It is assumed that just about all humans are somewhat dysfunctional (for innate and social reasons) but have quite different degrees and kinds of dysfunction. REBT especially emphasizes the cognitive elements in anxiety, depression and rage for several reasons: = Disturbed cognitions (Irrational Beliefs) are often easily accessible, even when they are just below the surface of consciousness. « Irrational Beliefs are frequently profound or core Beliefs that affect several important emotional and behavioral dysfunctions. = Changing a core Irrational Belief, can sometimes effect a remarkable change in several dysfunctional feelings and behaviors, as the change generalizes to other areas. Changing only an emotion or a behavior may lead to more limited improvement. = Making a profound philosophic change may reduce specific disturbances and also make the person less susceptible to future disturbances. = Sometimes a cognitive change can be understood quickly, in a few sessions, while emotional and behavioral changes usually take more time, effort, and persistence. For these and other reasons, REBT emphasizes philosophic methods, though it always uses several emotive and behavioralPersonality Disturbance and Change 27 methods as well to facilitate and reinforce the changes. It encourages you as a therapist to experiment in the first few sessions with teaching your clients the ABC’s of human disturbance, and how they can change B — their Belief System —and thereby often make some profound and lasting changes in C — their disturbed emotional and behavioral consequences. Here is the main cognitive therapy theory of REBT — its ABCs. People, again, are easily distressed when they have goals and purposes (G) to stay alive and be happy and free from pain and when Adversity (A) interferes and they do not get what they want, or do get what they don’t want. They have a choice of reacting to A with healthy negative feelings, such as sorrow, regret, and frustration, or reacting with unhealthy negative feelings, such as panic, depression, and rage. Largely, though not completely, they make this choice at B, their Belief System. When they choose rational or self-helping Beliefs, according to REBT, they often react with healthy feelings and actions; when they choose irrational or unhealthy Beliefs, they are more likely to react with unhealthy ones. Keep in mind that many clients, at least at first, may not believe that they are mainly responsible for their reactions. The idea that they have choices about how they feel may be very foreign to them. Most of us are not socialized to take responsibility for our reactions. This is seen most clearly in some the language we use to describe situations. “He made me angry,” “Tt really upset me,” “She caused me to do it.” These are all examples of the ways we attribute our emotions and behaviors to external sources. It may take a lot of work to show your client that, barring a mitigating biological condition, most times she becomes panicked, depressed, angry or otherwise irrationally upset, she’s making a choice to do so. This, in turn, means that she has the28 Rational Emotive Behavior Therapy power to choose a more flexible, realistic, and helpful reaction. This realization can be extremely empowering for clients. People choose their Irrational or Rational Beliefs largely on the strength of their desires. When their strong desires for success, approval, and comfort are negated by Adversities they often irrationally demand that these A’s absolutely must not exist. But when their desires are weak or moderate, they stick with rational preferences instead of musturbatory demands, and thereby less often disturb themselves when these preferences are not fulfilled. People’s evaluative Beliefs about Adversities are often automatic and unconscious; but they are also frequently conscious. What is largely unconscious is their knowledge that their Beliefs lead to (or at least significantly contribute to) their feelings. They usually have the illusion that they just feel bad about Adversity — that A “causes” C. Actually A x B=C. But since C frequently may occur almost instantly after A, they fail to see that B also importantly “causes” C. Particularly when A is very bad — say, they are falsely accused of theft — and they immediately feel enraged, they commonly think that the false accusation (A) by itself caused their rage (C), without realizing that their Beliefs (B) about A were also part of C. The ABC theory of disturbance also says that when dysfunctional negative emotions occur, people have many different kinds of Irrational Beliefs (IBs) but they have several core IBs in addition to their having Rational Beliefs (RBs). The common core IBs that they hold include: 1) Absolutistic musts and shoulds — e.g., “I must not be falsely accused.” 2) Awfilizing — ¢.g,, it is awful and horrible to be falsely accused.Personality Disturbance and Change 29 3) L-can’t-stand-it-itis — e.g., “I can’t stand being falsely accused.” When people say “I can’t stand it” they usually mean that the things they don’t like are so bad that they should not exist. This is called low frustration tolerance or discomfort disturbance. 4)Damning oneself and others — e.g., “Iam a rotten person if I am falsely accused and people think I really did steal.” “My accusers are bad people for falsely accusing me.” REBT hypothesizes that people’s core IBs interact with and influence each other. Thus, “I must not be falsely accused” often leads to the conclusion, “and it’s awful when I am.” But “It’s awful for me to be falsely accused” often also leads to the conclusion, “Therefore I must not be!” The Beliefs that Adversities absolutely must not exist even when they indubitably do exist, is probably basic to awfulizing, I-can’t-stand-it-itis, and damning of oneself and others, because if people only stayed with their preferences these seem to tacitly include a “but” that prevents the worst feelings of upsetness when they are not met. Thus, “I prefer not to be falsely accused,” implies “bur if I am, it is wot awful,” “but if I am, I can stand it,” and “but if I am, my accuser is not a wholly rotten person.” So absolute musts and must nots seem to underlie other core IBs. However, “I absolutely must not be falsely accused” implies that “Under all conditions and at all times I must never be falsely accused.” It is therefore an arrant overgeneralization. Damning oneself and other people, as Korzybski (1933) pointed out, stems from the overgeneralized és of identity: “I am what I do. If my act is bad, I am bad.” So along with musturbatory IBs we can look for basic overgeneralizations — evaluations of people and things that are illogical and unrealistic. Evaluating Adversities as awful30 Rational Emotive Behavior Therapy implies that they are zotally bad. Saying that we can’t stand Adversities implies that we can’t be happy ar all with them. Designating John and Jill as bad people implies that they only and always act badly. As far as your clients are concerned, you can show them that when they overgeneralize about Adversities in their lives, they can easily and profoundly disturb themselves. That will help them. But I have found that it is often simpler and easier for my clients to find their absolutistic musts and demands if they want to quickly see what they are doing — at B, their Belief System — to make their Adversities into emotional holocausts. An effective REBT maxim is “Cherchez le should! Cherchez le must!” “Find the should! Find the must!” This slogan will not tell your clients the whole or sole cause of their disturbances. But it will help them see the source that is one of the main accessible contributions to upsetness and that they have the ability to change. Is the human Belief System involved in disturbances that are largely biological, such as endogenous depression and obsessive compulsive disorder (OCD), and those related to severe trauma, such as post-traumatic stress disorder? Very probably. In endogenous depression, neurotransmitters, particularly serotonin, work inefficiently to produce distorted perceptions and thoughts of a depressive nature; and in OCD several kinds of cognitive functions work poorly, such as fixed ideas, constant ruminations, and inability to do normal checking. Depression and OCD sufferers get depressed and anxious feelings, often without clear-cut causes, about which they then awfulize and damn themselves. In PTSD the intensity, unexpectedness, and strangeness of traumas vastly shock people and lead to thoughts of severe rage, guilt, and self-deprecation. Also, the fear of the traumasPersonality Disturbance and Change 31 reoccurring keeps the original feelings and panicked thoughts alive, sometimes for many years. The REBT theory of disturbance can therefore explain much of the disturbance, and the disturbance about the disturbance, of many dysfunctions that have biological or severe environmental aspects. REBT Theory of the Maintenance and Heightening of Emotional Disturbance Once people become emotionally disturbed — for whatever reasons — their cognitions play a very important part in maintaining their dysfunctions. They remember Adversities, perceive that they could recur or worsen, and frequently demand a guarantee that they end. This keeps current “horrors” in mind and imagination augments and sustains them. To make matters much worse, people often have Irrational Beliefs about their symptoms. Thus, Marcella had the IB that she absolutely had to do well in school, and whenever she experienced the Adversity of getting less than an A, she felt the Consequence (C) of depression. But then she made her depression into a real Adversity (A?), told herself at IB?, “I must not be depressed! It’s awful to be depressed!” and wound up depressed about her depression (C?). Her condition went from bad to worse. Marcella saw AE for REBT, and at first agreed with its teachings but didn’t improve. She then made failing at therapy into Adversity? and created IB? about her failure, especially, “I must do well at therapy! Pm no good for not working hard enough at it!” So she made herself depressed about her initial failure at therapy. In reverse order, AE helped her first accept herself while failing at therapy; second, accept herself in spite of her depression; and third, accept herself with a B or a C in a course. This triple-header unconditional32, Rational Emotive Behavior Therapy self-acceptance (USA) challenged her core IBs about the necessity of doing well to be a worthwhile individual and helped her acquire several profound Rational Beliefs. The REBT. Revealing of ‘Irrational Belief eee As noted previously in this book, several thinkers and therapists have come up with the idea that people largely disturb themselves with dysfunctional Beliefs. But which specific Beliefs they commonly used were not detailed and categorized until 1956, when AE first described twelve of them that were often used by clients when they were disturbed. Then, after using REBT for a couple of years, AE realized that just about all the IBs clients held that helped make them and keep them disturbed could be placed under three major headings. Perhaps more importantly, each of these core dysfunctional Beliefs included an absolutistic must or demand. If, however, people held these same Beliefs as preferences or wishes, and rigorously refrained from escalating them into grandiose demands, they would minimize much (not all) of their disturbances. This, if valid, was a startling revelation; for it simplified the main cognitive factors in clients’ upsetness, made them easily observable if therapists and clients looked for them, and presented workable solutions to changing them. The three main musturbatory Irrational Beliefs that AE came up with were these: 1)‘I absolutely must under all conditions do important tasks well and be approved by significant others or else I am an inadequate and unlovable person!” This Belief often results in anxiety, depression, and feelings of worthlessness or self-damnation when clients don’t function as well as they supposedly must. It includes thePersonality Disturbance and Change 33 illogical overgeneralizations of all-or-nothing thinking and labeling. Considering human fallibility, it is highly unrealistic. 2) “Other people absolutely must under all conditions treat me fairly and justly or else they are rotten, damnable persons!” This Irrational Belief often results in anger, rage, feuds, wars, genocide, and the denigration of others as a whole rather than mere judgement of their “bad” acts. Again it includes illogical overgeneralization and labeling and is unrealistic in the light of human fallibility. 3) “Conditions under which I live absolutely must always be the way I want them to be, give me almost immediate gratification, and not require me to work too hard to change or improve them; or else it is awfisl, I can’t stand them, and it is impossible for me to be happy at all!” This IB results in low frustration tolerance or discomfort, disturbance, depression, procrastination, and inertia. It damns life or the world for being worse than it supposedly should be. Once again, it is illogical (for conditions, right now, are as “bad” as they are) and it is unrealistic (for ideal conditions rarely exist). REBT doesn’t oppose — in fact, it encourages — striving for success, approval, and comfort, as long as we prefer rather than absolutely need these things. Why? Because we are natural goal-seekers, enjoy striving, and usually (not always!) get better individual and social results. But when we (consciously or unconsciously) demand satisfactions, and well may not achieve them, watch it! Unhealthy misery, rather than healthy34 Rational Emotive Behavior Therapy disappointment, frequently ensues — along with all kinds of unnecessary interferences. In teaching your clients how to discover their dysfunctional, self-blocking Beliefs, should you try to help them uncover the specific IBs that encourage them, say, to feel depressed? Yes, by all means, as that will usually help them go on to D in the ABC’s of REBT — Disputing their specific IB (which we discuss in chapter 5). But if they are depressed, consider first looking for all three of the major IBs to see if they can be found. First, consider IB No. 1, “I must do well and gain approval!” A likely suspect when your clients feel depressed, as it often leads to self-downing. Are they really insisting that they do well in important tasks and/or be approved of by significant others? Get them to ask those questions as you, considering their goals and values, also do so. Second, are your clients demanding that other people treat them well, and making themselves angry and depressed if these others are not acting the way they supposedly must? A real possibility — both of you had better explore it. Third, are your depressed clients commanding that conditions must be good and have to give them what they want when they want it? Are they depressing themselves, with their low frustration tolerance, when conditions are not as good as they absolutely should be? Probably. But don’t assume that they have this unrealistic IB — look for fairly clear evidence of it, and help them look, too. The great value of REBT’s hypothesizing three major Irrational Beliefs that often lead to disturbance is that you can fairly quickly, when the client presents a distinct emotional or behavioral. problem, check to see if he or she holds one or more of the three and see if it is connected with this problem. Don’t assume that it is connected — only assume that it may be held andPersonality Disturbance and Change 35 that it may be connected. Often, and in a time-saving manner, you will be accurate. Once you and the client discover a core IB, you can look for its subheadings and variations. For example a depressed client’s Belief, “I absolutely must do well and be approved by significant others,” may lead to other core derivative IBs. Such as: = Avfulizing: “Its awful when John criticizes me!” = I-can*t-stand-it-itis: “I can’t stand Mary’s rejection!” = Overgeneralizing: “If John and Mary criticize me, everyone also will, and Pll be totally alone!” = Jumping to conclusions: “If John and Mary criticize me, I must be acting badly!” = Focusing on the negative: “Mary is frowning, so she must be frowning at me.” Disqualifying the positive: “John wants to go out with me but that’s only because he has pity on me for being so inadequate.” = Minimizing the good things: “I spoke well in my conversation with John today, but I usually talk badly and he has a generally bad impression of me.” Personalizing: “Mary says she’s too busy to see anyone but she really means she doesn’t want to see me.” = Phoneyism: “I went out of my way to be nice to John this time, but P’'m really a phoney and far from a nice person.” a Perfectionism: “I got along nicely this time with John and Mary, but I made some stupid errors which I36 Rational Emotive Behavior Therapy wouldn’t have made if I were a perfectly adequate person. As I should be!” Tf you and your clients turn up any important Irrational Beliefs that are leading to the feelings of depression, highlight them, show how they are connected with their depression, and show why they are unrealistic, illogical, and harmful. But at the same time reveal how they are involved with core IBs that they usually make pervasive and important. The more you can help clients to reveal and surrender their core IBs, the more they can understand how to zero in on them, as well as to uncover their more specific and more limited IBs. Helping Clients See the Connection Between their Beliefs, Feelings, and Actions One of the most important and self-sabotaging Irrational Beliefs held by disturbed clients is that, following Adversity (A) they automatically just have feeling and behavioral Consequences (C). Typical self-statements: “Closed spaces make me anxious.” “You made me angry by treating me unfairly.” “T felt like a worm when they laughed at me.” These are partially accurate statements of A (Adversity) and C (disturbed) feelings. But they omit the very important “B” factors — your clients’ Beliefs about A. A alone clearly doesn’t lead to C, for ifit did all people in closed spaces would feel anxious, all would feel angry when they see others treating them unfairly, and all would feel like worms when they were laughed at. Obviously, and frequently, they all don’t. Helping your clients discover their IBs when they feel seriously disturbed may not be enough. Jonathan saw and “knew” he was often thinking irrationally when he concluded that his friends disliked him for beating them at tennis, even though theyPersonality Disturbance and Change 37 congratulated him and acted nicely to him after the game. Most of the evidence showed that they disliked losing the match but still liked him. Nevertheless, he still was angry at them for wanting to play with others, with whom they could succeed, rather than with him. He blamed his anger on the Adversity of their refusing to play with him. He at first didn’t see what he was telling himself at B, namely, “They shouldn’t avoid playing with me even if they lose. They'll play a more interesting and better game. They should really like me in spite of my winning and they don’t like me well enough! Those lousy bastards!” So Jonathan “saw” that his friends disliked him after he won a match, also “saw” that he exaggerated their dislike, but didn’t see that his anger (C) stemmed not just from their refusal to play with him (A) but also from his Be/efs (B) about their refusal. When AE helped him to recognize B and its important contribution to C, he accepted the unpleasant fact of his friends? refusal to play. He made their playing with him a preference instead of a demand and felt sorry and disappointed about their refusal rather than angry at them. Unless clients do see the BC connection, and realize that they can quickly find and change B, they will fail to learn and use one of the most important insights of REBT — and probably of therapy in general (Ellis & Dryden, 1997; Ellis & Harper, 1998; Walen, DiGiuseppe, & Dryden, 1992). The Use of Insigi ht in REBT Because it stresses cognition more than do some other therapies, REBT naturally emphasizes the importance of insight — of your clients recognizing what internal and external influences contributed to their disturbances and seeing what they can do to use them to improve their emotional and physical health. However, as noted above, REBT holds that insight itself may only38 Rational Emotive Behavior Therapy partially help, and that understanding of the details of the past may interfere with understanding and changing present sources of dysfunction. REBT therefore emphasizes three main kinds of insight that are likely to help clients in the present. Insight No. 1: (the ABC’s of human disturbance): A (Adversity) often contributes significantly to C (Consequences) of disturbed feelings and behaviors, but so does B (Beliefs about A). Ax B=C. Insight No. 2: Even though disturbed C’s frequently originated following Adversities (A’s) in childhood and adolescence, they shen were partially created by grandiose (though natural) IBs; and it is largely the continued Belief in these IBs that keeps the clients disturbed today. So they had better see these present and past IBs and change them to get better consequences today. Insight No. 3: To improve clients’ dysfunctional Consequences today usually requires a good deal of insight and work and practice — cognitive, emotive, and behavioral work and practice — because they have biological, learned, and habituated tendencies to maintain them (Ellis, 1994, 1996). Getting Better Rather than Just Feeling Better “Helping people get better rather than merely feel better” (Ellis, 1972) is one of the key factors in REBT. The following points illustrate how that process works: 1) Clients come to see you, their therapist, to relieve their presenting symptoms — such as disturbedPersonality Disturbance and Change 39 emotions (c.g., severe anxiety, depression, rage, self-downing, and self-pity) and to stop their harmful compulsive reactions (¢.g., violence, child abuse, over drinking, substance abuse, gambling, smoking, and overeating) and their withdrawal reactions (e.g., social phobias, public speaking phobias, and procrastination). Fine. First, help them minimize these self-defeating and socially harmful feelings and behaviors and preferably stop them in their tracks. 2) Clients, when they reduce the symptoms that bother them most, can be helped to minimize related or not-so-related thoughts, feelings, and behaviors. Thus, if they reduce their social anxiety, you can somewhat similarly show them how to reduce their work, their educational, their hypochondriacal, their phobic, and their other anxieties, which they may at first ignore or even be little aware of. Using the principles of REBT, they can be helped to minimize almost any kinds of anxiety, depression, and rage. 3) To get better, and not merely feel better, you can help them to rarely be anxious, depressed, or enraged about people and events that they have often upset themselves about previously. Their profound New Effective Philosophies become habitual and they rarely revert again to their former core Irrational Beliefs. 4) When they do upset themselves again, they can fairly easily reuse the various effective cognitive, emotive, and behavioral methods that you have taught them and helped to practice using before. Then they can frequently do so by asking themselves, “What REBT techniques have I used before to deal with this problem40 Rational Emotive Behavior Therapy that I can now use again?” Solution-focused therapy (deShazer, 1985) uses a somewhat similar technique. 5) If new Adversities arise in their lives — or they make them arise — they can use their knowledge of REBT and the profound New Effective Philosophies they have learned by using it to stubbornly refuse to make themselves miserable about almost anything that is likely to plague them during their lives. 6) If using REBT under specially adverse conditions does not seem to be working, they can return to you (or another REBT therapist) for some sessions, to help guide them back to an effective therapeutic groove. These steps which are discussed in more detail in a journal article (Ellis, 1972), outline the process of using REBT to get and not merely feel better. No form of therapy works well for all clients all of the time. But it is hypothesized that REBT, when strongly and persistently used, will help some people reach this “elegant” solution of getting better more frequently than will other forms of therapy. The Reciprocal Influence of Adversities, Beliefs and Consequences (Emotions and Behaviors) on Each Other ‘peor nmntsntmersceenna As briefly noted before, Adversities (A), people’s Beliefs (B) about them, influence and “cause” C, their emotional and behavioral Consequences. A x B=C. But, as also noted, thoughts, feelings, and behaviors are not pure but include and are integrated with each other. Similarly, though REBT especially emphasizes A’s and B’s influence on C, it also sees A affecting B and C, B affecting A and C, and C affecting A and B.41 Personality Disturbance and Change 94q2s07014 10 ye 1 Sujoos 5) ays ew Buxouve . PUOU MOU ® Puy pue INO 06 UD MoU pue Sw] oid £1 2x64 IP u nq ~PuD i! 295 01 Auos W| PUE nq ‘ouoewos 9943 10 aoUanbasuoD leuonowy Man {(uosied peq eeu 40) uosied eq aw oyew dey Buyuong, “inne st StL, soypue _ 24 Wem Aqiss0d PInoo suo ou ‘10joH04) ‘ous yueM 14s90p aus. 204 2 UEWON teoi6 soyioue puy sanou se0i4uom @ 04 Ishi A .cavoye Addey 0q jupine9 | 1841 von 10 ‘asj@ auoawos yim dys -voueja: poo6 feat & aney 01 age oA yim dhysuosteyo: 94 yo yea 0} Seysim asojaray: pur “uew 2ompue Noissaudaa “24 eal BOUEPHNe OW 5.8104. ‘seap| jeuone| aouayedx3 ayy ynoqy syolleg jeuonyed4y saouenbasuog jeuonowy Buryasdy 3 sone 104) aye) AOYL YDIYA SMOIA OF KG ING "SSuIKN Ay YoU PaqiMip axe aydoad,, aoueqsnisig jeuoowy jo Auoaus 0-9-7 s,Adesoyuy solaeyog aaljowg jeuoney42 Rational Emotive Behavior Therapy Jodi resisted looking for a better job largely because of her two Irrational Beliefs: 1) “I must not fail job interviews or else Pm a hopeless loser.” 2) “Preparing for and taking job interviews is too hard and requires too much effort. Pll wait till someone offers me a new job.” So she decided to change these IBs and go for job interviews. But she also observed that at A (Adversity) she had little education and training for the kind of job she wanted, that good jobs were scarce in her area, and that some employers thought she was too old (age fifty-five) to work very long before she retired. So these hard facts at A influenced her to have negative thoughts at B, and avoidance of interviews at C. Jodi’s job-avoidance (C) also temporarily decreased her anxiety (C) because she couldn’t be rejected, but in the long run increased it, because she wasn’t able to disconfirm, in practice, the “awfulness” of rejection. In fact, the less she got rejected, the more “awful” she imagined it would be. So her job-seeking avoidance (C) also “confirmed” her Irrational Belief (B), “It’s awful to be rejected — as I must not be!” When Jodi more fully saw the ABCs of her job-avoidance she concluded, “It really is hard for me to get the kind of job I want butifI stop telling myself, ‘I must not be rejected,’ and accept the fact that often I will be, I really have nothing to lose. I'll stop seeing job-hunting as to hard, push myself uncomfortably to do it, get familiar with doing it, and overcome my self-induced great fear of job-seeking.” Fully looking at her ABCs helped Jodi actively look for a better job. /\ B cPersonality Disturbance and Change 43 When two or more people relate to each other, their A’s not only influence their Bs and Cs, their Bs influence their A’s and Cs, and their Cs influence their A’s and Bs, but also their A’s, Bs, and Cs often affect each other’s A’s, Bs, and Cs. Bruce and Grace were married and critical of each other. At A (Adversity) Grace took Bruce’s criticism, told herself at B (Beliefs about A), “Bruce must not criticize me so much! I can’t stand him!” and made herself enraged at him at C. Bruce observed Grace’s anger (at C) and made it into his Adversity (A). At B, he told himself, “She’s always angry and that means I must be doing something wrong. I’m really inadequate!” So at C he felt depressed. Then Grace observed Bruce’s depression (his C) and made it into her Adversity? — “I dislike Bruce’s being depressed by my anger.” She then told herself, “I depressed Bruce with my anger, as I shouldn’t have done” (B?) and she felt, at C?, guilty. Bruce then saw Grace’s guilt (her C?)and made it into his A”, disliking himself for causing Grace guilt. At B?, he told himself, “T shouldn’t make Grace guilty. Pm really a worm for doing so!” At C? he felt guilty and more depressed than ever. Obviously, then, people’s ABCs can importantly and reciprocally influence their other A’s, Bs, and Cs; and they can affect, and also influence others’ A’s, Bs, and Cs. They can then help disturb, though actually not directly disturb, other people, especially ones with whom they are intimate. In relationship therapy, REBT shows couples how they affect each other — but not actually directly disturb each other — as they very often mistakenly conclude (Ellis, 1957; Ellis & Harper, 1961; Ellis, Sichel, diMattia, Yeager, and DiGiuseppe, 1989). It then helps them Dispute their various Irrational Beliefs that largely create their upsetness.44 Rational Emotive Behavior Therapy The Advantages of Active-Directive REBT Some disturbed people are thoroughly tired of their dysfunctional feelings and behavior, fully ready to go through the discomforts of changing, and — on their own or with self-help materials — push themselves to change. Fine! — as clients they make good customers. But even though they are bright and constructivist, many change more slowly — or very little. Why? For several reasons: = They may be biologically prone to be severely disturbed — e.g., have serious personality disorders, and have more trouble doing so than average “nice neurotics.” = They may have low frustration tolerance and won’t take the time and the effort usually required of change. « They may view improvement as “dangerous” because it takes away their excuses for not taking risks that they may fail at. « They may be more interested in the therapist’s approval and continuing therapy with a caring therapist than in getting better and being on their own. = They may be hostile to others — such as their mates — who push them to change. = They may not agree with a particular kind of therapy, such as REBT. « They may have various other reasons for resisting (Ellis, 1985).Personality Disturbance and Change 45 When clients resist therapy, it is usually best to refrain from continuing passive methods (forever!), but to actively-directively determine what are their main reasons for resisting, whether they are good reasons (which they may be), and how to help overcome them (if feasible). The theory that if you merely show them their IBs and how to modify them (or otherwise are indirect and less active as a therapist) they will somehow, as constructivists, find their way to good solutions, has very little evidence to back it. Much more evidence shows that active-directive revealing, finding the reasons for, and uprooting clients’ resistance often works. If it doesn’t, it still may reveal salient reasons for it, and encourage them to use a different form of therapy. Active-directiveness on your part, moreover, has many other advantages. It shows what will probably be effective for this particular client — who in some ways is different from other clients. It may well work for briefer and effective therapy for some hard-working clients. It helps teach some of the fundamental theories and practices for clients to choose from. Clients are usually in pain when they start therapy and rapport is enhanced by showing them that you can competently guide them into new, less painful ways. Therapy is expensive of the client’s time and money and your time and effort, and active-directive (hopefully brief) therapy makes it less expensive. More passive methods of therapy, such as classical analysis and Rogerian person-centered therapy have been shown to “sneak in” directive and subtle reinforcement techniques — because often they alone will work. Many good therapy methods, such as exposure to fearful stimuli and events, have to be directively taught and encouraged. Directiveness emphasizes self-efficacy, which gives clients the confidence they can accomplish many things they are convinced that they cannot do. Directiveness is practically necessary with some clients who have severe personality disorders or other46 Rational Emotive Behavior Therapy biological or acquired limitations and who require the therapist’s activity to push them to overcome these limitations. REBT, because of these advantages, is usually quite active-directive. But, as a therapist, you had better keep in mind that practically all good things also have disadvantages. Active-directiveness may therefore interfere with your clients’ innate proactive tendencies to solve their own problems and to actualize themselves. It may too-strongly present goals and values, and methods to achieve them, that your clients too-suggestibly accept. You may, asa directive therapist, especially in some cases, take over too much responsibility and power, and thereby interfere with a collaborative and cooperative client-therapist relationship. AE has described several cautions for therapists to take in being overly-directive (Ellis, 1997). These include: = Be aware of the limitations of the therapy techniques you use. « Monitor your clients’ different reactions to the techniques you recommend and be prepared to stop or modify some of them with individual clients. « Have many cognitive, emotive, and behavioral methods available, including some more passive methods, which you can at times borrow or steal from other systems of therapy. « Give unconditional acceptance or Rogers’ (1961) unconditional positive regard to all clients and show them how to give it to themselves, so that they neither denigrate themselves nor down themselves when they fail to use your “good” methods.Personality Disturbance and Change 47 Caution, caution! The more active-directive you are, the more you may help and harm clients. This is particularly true with supersensitive people who are prone to self-denigration. Though you may personally favor active-directive therapy, be careful and always be ready to withdraw. Therapy is often a zigzag instead of a straightly ascending process. Often let it be! Let us say, in concluding this section, that we have seen some fairly passive, nondirective therapists use REBT and CBT successfully. They go slowly and carefully, because that is their nature. Or, because they passively try to let their clients come to their own conclusions about their IBs, how to Dispute them, and how to feel and act against them. Some REBTers almost exclusively use the Socratic dialogue method of helping clients to question and challenge their IBs. This method, since the therapist uses questions, such as “What did you tell yourself when you were anxious about your procrastination?” and “Is it really true that you must have guaranteed success in presenting your point of view?” is really quite active. But it is hardly as directive as saying, “Didn’t you demand that you must present well?” And, “Obviously you don’t have to present well and would be much less anxious if you only preferred to do so.” Again, probably all therapists are somewhat active-directive. But as an REBT and CBT practitioner, you have the choice of how much to be with individual clients. Try to exert that choice wisely! Discover what works best with this particular client at this time. Experiment! Summa = Biological tendencies, environmental conditions, and social conditions all contribute to the reasons that people become upset or disturbed.48 Rational Emotive Behavior Therapy REBT focuses primarily on the cognitive elements of disturbance because changing a core irrational belief can subsequently cause profound improvements emotionally and behaviorally. In the “ABC” model of REBT, the “A” is an activating event or adversity which one experiences in his life such as a situation, person, thought, etc. The “C” is the emotional and/or behavioral consequence connected to the “A.” The “B” is the belief about the “A,” activating event, which actually causes the “C,” consequence. Beliefs can be rational or irrational, Rational Beliefs (RBs) are flexible, adaptive, consistent with social reality and help us achieve our goals in life. Irrational Beliefs (IBs) are rigid, dogmatic, inconsistent with social reality and generally get in the way of goal attainment, REBT focuses on not only helping the client feel better in her current situation but also on teaching her to get better by using the principles in future situations. An active-directive approach to therapy allows for briefer, effective therapy which allows for “teaching” opportunities and can provide added motivation to push the client forward at potentially less expense to the client.The Process of Assessment in REBT EBT is somewhat skeptical of rigid diagnostic categories, R= as are described in DSM-IV, because they sometimes label people in an overgeneralized way. They may be useful, however, in deciding how severely disturbed your clients are, how long it may take to help them, and what methods may be most useful for individual clients. Assessment methods that are favored are cognitive-behavioral tests and materials (Kendall & Hollon, 1980), rather than psychodynamic tests, such as the Rorschach test, which are open to many different interpretations. No tests are sacred, because even “objective” tests of clients’ acknowledged Irrational Beliefs may be consciously or unconsciously prettified. In our intake packet at the New York Institute, we include some standardized tests as well as forms to collect general biographical data, and prior therapy experience information. We also have clients retake a “satisfaction of life” assessment every four to six weeks to aid in charting progress. Assessment includes: 1) What are clients’ specific cognitive, emotional, and behavioral disturbances and lack of skills (Cs)? 4950 Rational Emotive Behavior Therapy 2) What Activating Events or Adversities (A’s) commonly accompany their undesirable Consequences (Cs) ? 3) What Rational Beliefs (RBs) and Irrational Beliefs (IBs) tend to evaluate A’s and lead to dysfunctional Cs? 4) What cognitive Disputes (D) as well as emotive and behavioral methods are likely to help clients retain their RBs and change their IBs, so that they strongly and persistently arrive at Effective New Philosophies of life (E's)? 5) What thoughts, feelings, and actions will best maintain the clients’ progress and preferably help them to actualize and enjoy themselves more? We usually advocate identifying your client’s problematic Consequences (Cs) first as this is the topic that they generally present with and it helps you to assess whether they are feeling/behaving rationally or have irrationally upset themselves over something in their lives. To get the Cs, you can ask, “How do you feel about that?”, “How do you physically feel when that happens?”, and “What do you do?” Responses to these questions vary greatly and you may have to probe deeper to really understand what’s going on in these situations. A client may report that he feels “upset.” This is a start, but you want to assess what type of upsetness he is experiencing. Is it anger, depression, jealousy, anxiety, or a combination of things? Is it sadness, frustration, or disappointment? In these cases it may be a rational response. Is your client irrationally overeating when she perceives she is being treated poorly or does she rationally choose not to spend time with the people who don’t behave well toward her?‘The Process of Assessment in REBT 51 Morgan began his first therapy session by stating that he was upset with his business partner, Bill. When asked about the nature of the upset, he reported feeling anger and disappointment. His disappointment stemmed from not having the kind of working relationship with Bill that he would have liked to have. This was reasonable and based on a desire that wasn’t being fulfilled, so we decided to work on the anger because Morgan’s anger was unhealthy and was causing him a great deal of stress. Once you have identified the Cs and have agreed to the most important or pressing Consequence that your client would like to work on, it’s time to thoroughly assess the A’s (Activating events or Adversities) that precipitate the Consequences. If there are several Cs, you will have to spend some time prioritizing what to work on and in what order. Clients rarely, if ever, experience their upset all of the time. Therefore, it is important that you help them to identify the particular situations, people, or thoughts which trigger their unhelpful Consequences. Helpful questions include, “When do you feel/behave that way”, or “Which situations usually result in that Consequence?”, You can also have your client relate the most recent experience he had with the Consequences in order to get a sense of the A’s. Morgan became angry with Bill in situations where he believed that Bill was not “pulling his weight” in the office. Recently, Bill had left work early to go to a baseball game instead of staying to finish the day’s business. Morgan had not only stayed late to finish the work but had also fumed about it the entire evening and had trouble falling asleep because of his invasive thoughts about Bill’s “lazy work ethic.” He then behaved abruptly and was unfriendly toward Bill for the next couple of days. Morgan reported that these types of scenarios happened once or twice a week.52 Rational Emotive Behavior Therapy The next step is to identify the Bs (Beliefs) which cause the reactions (Cs). Appropriate queries are, “What are you telling yourself when you make yourself (jealous) (depressed) (overeat) etc.?”, and “How are you making yourself (angry) (anxious) etc.?”, and “What’s going through your head while you’re feeling/behaving this way?” You will usually elicit both rational and irrational beliefs with these questions. Keep in mind that: Rational Beliefs (RBs) are those which are healthy, productive, adaptive, and consistent with social reality. They generally consist of preferences, desires, and wants. Irrational Beliefs (IBs) are rigid, dogmatic, unhealthy, maladaptive, and mostly get in the way of our efforts to achieve our goals. IBs are comprised of demands, musts, and shoulds. It’s your job to work at identifying and positively reinforcing the rational statements (RBs), while taking note of the irrational statements (IBs) which are the beliefs which contribute the most to the unhealthy Cs. The goal is to attempt to uncover hidden demands (shoulds), awfulizing, global self- or other-downing, and low frustration tolerance (I-can’t-stand-ititis). You may have to ask several times or many different ways in order to accomplish this task. Morgan said that when he became angry at Bill his thoughts included, “it’s not fair that I have to work so hard and he doesn’t,” “he’s not putting in enough time (as he should),” “he’s a real jerk for putting me in this situation,” and “I wish I got to take breaks like that.” The last statement, again, was healthy and rational. Morgan’s desire to take breaks wasn’t getting him into any real‘The Process of Assessment in REBT 53 trouble. It led him to feel disappointed but didn’t cause him to feel overly upset or act in any inappropriate ways. The first two beliefs, however, were getting Morgan into a lot of trouble. He was rigidly and irrationally demanding that Bill not be the way he obviously was. He was also globally labeling Bill as a complete Serk” because of his behavior in this one area. In addition, he was strongly and illogically believing that because he thought Bill should put in more time, he therefore ought to. Finally, he was exhibiting some low frustration tolerance in his belief that he, Morgan, shouldn’t have to work so hard. After identifying the ABCs of a particular Consequence with your client, you can then begin to scrutinize, evaluate, test, and ultimately, hopefully, replace the IBs which have surfaced during this assessment. Chapters 5, 6, and 7 discuss various approaches to use. Of course, since some clients aren’t familiar with the ABC model, it may take longer to work through the initial assessments until you begin to feel more comfortable with REBT and your client becomes more knowledgeable about it. One way to facilitate the experience is to discuss the REBT model and theory with your clients at the very beginning of therapy so that they have a basic understanding of it and an opportunity to ask questions if necessary. Often, with experience, clients will begin to present their problems in the ABC format but, as with most things, this comes with practice! Something else to keep in mind, as in the example of Grace and Bruce in chapter 3, is that Cs can often become A’s for your clients. This means that a Consequence can become the trigger for a whole separate ABC assessment and exploring this possibility is equally important in assessing the problem. For example, when Morgan became angry at Bill, he later felt guilty about it and put himself down. Thus, his anger (the C in the first example), became a secondary A in that it led to feeling guilty and54 Rational Emotive Behavior Therapy self-downing. This was due to self-statements (IBs) like, “I shouldn’t have been so mean to Bill,” “It’s terrible of me to get so angry at a friend,” etc. You can assess for secondary problems by asking, “How do you feel about yourself for being (angry) (anxious) (depressed) etc. and/or for behaving like that?”. As a rule of thumb, if you find that your client is experiencing secondary or even tertiary upset about the problem, it’s best to start with the tertiary (or secondary) upset and work your way back to the primary problem. Incidentally, clients may also initially present what turns out to be a secondary problem as the main problem so it’s important to keep asking questions and formulating and testing hypotheses throughout therapy. Assessment in REBT is an ongoing process. Therapy itself is usually relied upon as the main method of diagnosis. For it is quickly seen, when using REBT, what Adversities (A’s) your clients most upset themselves about, what IBs they have about these A’s, how accurately they can recognize their IBs, how well and forcefully they Dispute them, what Effective New Philosophies (E’s) they devise, etc. You can see the most important aspects of their disturbances and how they use REBT methods to change or not change themselves. You can thus keep teaching and following up on the more effective methods of changing and dropping the less effective methods for each individual client. Moreover, you don’t have to stick with favorite REBT techniques but can at times use less favored ones — and even use techniques from other systems that you generally disfavor. There are no musts about using many possible REBT and non-REBT methods — only preferences that are guided by their effectiveness with different clients. As Paul (1967, p. 11) has observed, you ask yourself, “What treatment, by whom, is most effective for this individual with that specific problem, and under which set of circumstances?” As usual, REBT above all is flexible!