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When REBT Goes Difficult: Applying ABC-DEF to Personality Disorders

Article in Journal of Rational-Emotive and Cognitive-Behavior Therapy · December 2016

DOI: 10.1007/s10942-016-0258-7

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When REBT Goes Difficult: Applying ABC-
DEF to Personality Disorders

Diego Sarracino, Giancarlo Dimaggio,

Rawezh Ibrahim, Raffaele Popolo,
Sandra Sassaroli & Giovanni
M. Ruggiero
Journal of Rational-Emotive &
Cognitive-Behavior Therapy

ISSN 0894-9085
Volume 35
Number 3

J Rat-Emo Cognitive-Behav Ther (2017)

35:278-295
DOI 10.1007/s10942-016-0258-7

1 23
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 Author's personal copy
J Rat-Emo Cognitive-Behav Ther (2017) 35:278–295
DOI 10.1007/s10942-016-0258-7

When REBT Goes Difficult: Applying ABC-DEF

to Personality Disorders

Diego Sarracino1 • Giancarlo Dimaggio2 •

Rawezh Ibrahim3 • Raffaele Popolo2 •
Sandra Sassaroli6,7,8,9,10 • Giovanni M. Ruggiero4,5,6,7,8,9,10

Published online: 23 December 2016

 Springer Science+Business Media New York 2016

Abstract ABC-DEF framework is at the core of rational emotive behavior therapy.

It is a highly flexible framework and has proven to be applicable to many emotional
disorders. We cannot take for granted, however, that this framework can be used
successfully with all clients, particularly with those suffering from severe disorders
or personality disorders. In fact, the difficulties of these clients in recognizing,
naming and reflecting upon states of mind, their dysregulated emotions and self-
defeating behavior, and their difficulty in establishing a strong working alliance
with a therapist may hamper the correct implementation of the ABC-DEF frame-
work and the disputing of their irrational beliefs. This paper aims to describe in

& Giovanni M. Ruggiero

[email protected]
1
Department of Psychology, Milano Bicocca University, Piazza dell’Ateneo Nuovo 1,
20126 Milan, Italy
2
Centro Terapia Metacognitiva Interpersonale (TMI), Piazza dei Martiri di Belfiore, 4,
00195 Rome, Italy
3
University of Raparin, Ranya, Iraq
4
‘‘Psicoterapia Cognitiva e Ricerca’’ Cognitive Psychotherapy School and Research Center,
Milano, Foro Buonaparte 57, 20121 Milan, Italy
5
‘‘Psicoterapia Cognitiva e Ricerca’’ Cognitive Psychotherapy School and Research Center,
Bolzano, Italy
6
‘‘Studi Cognitivi’’ Cognitive Psychotherapy School and Research Center, Foro Buonaparte 57,
20121 Milan, Italy
7
‘‘Studi Cognitivi’’ Cognitive Psychotherapy School and Research Center, Modena, Italy
8
‘‘Studi Cognitivi’’ Cognitive Psychotherapy School and Research Center,
San Benedetto Del Tronto, Italy
9
Sigmund Freud University, Ripa di Porta Ticinese 77, 20143 Milan, Italy
10
Sigmund Freud University, Freudplatz 1, Messestraße 1, 1020 Vienna, Austria

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detail the challenges that clients with personality disorders may pose during treat-
ment and offer possible technical suggestions, derived from either REBT or non-
REBT literature, that can help REBT and CBT practitioners adapting their inter-
ventions to resistant clients.

Keywords ABC
ABC-DEF
Rational emotive behavior therapy
REBT

Disputation
Personality disorders

ABC-DEF is a highly flexible framework that not only plays a central role in the
clinical success of REBT, but—being in the historical forefront of the cognitive
trend (Haaga and Davison 1993)—also inspired the principle of all cognitive
therapies supposing that emotional disorders depend on cognitions (Beck 1976;
Clark et al. 1999). The client is asked to agree that external events (A) do not cause
emotions (C), but beliefs (B) and, in particular, irrational beliefs (IB) do
(DiGiuseppe et al. 2014, pp. 81–83). However, to apply an ABC-DEF framework
and dispute clients’ IB, a therapist needs a strong working alliance with the client
(DiGiuseppe et al. 2014, pp. 82–86. We cannot take for granted that all clients can
or are motivated to work on their ABCs, especially if they suffer from severe
disorders or personality disorders (PDs). Ellis noted that clients with difficulties that
now are considered the hallmark of PDs—such as emotional dysregulation,
destructive self-defeating behaviours, and self-punishing beliefs—experienced
difficulty in challenging their IBs (Ellis 2002, pp. 176–193). In general, many
clients with PDs are resistant and non-cooperative (Beck et al. 2014; Ellis
1994, 2002; Golden 1983; Leaf et al. 1991; Leahy 2003, 2008; Ogrodniczuk et al.
2005). An indirect confirmation of this comes from studies that have shown how
negative personality traits are associated with high levels on many and sometimes
all IBs; these results—although related to personality but not to PDs—nevertheless
suggest that a difficult personality trait can contribute to create particularly
problematic clients (Leaf et al. 1991; Harnish and Bridges 2014; Samar et al. 2013).
In fact, many PD sufferers do not formulate their disorders in psychological
terms and hardly understand that therapy acts on their psychological states and not
on their external situations (Dimaggio et al. 2015). In REBT terms, clients with PD
awfulize conflicts, disagreements and misunderstandings, demand that there should
not be any interpersonal conflict or tension, consider unbearable any frustration
linked to these conflicts, and have unrealistic, global views of themselves and others
(Ellis 1994).
This paper reviews both the REBT and non-REBT scientific literature focused on
the typical challenges that clients with PD present during treatment in order to
1. Understand whether this kind of clinical literature might help show if and how
in some clients the full implementation of the ABC-DEF framework is uneven;
2. Compare REBT and non-REBT clinical literature concerning clients not prone
to establish a therapeutic working alliance; and
3. Offer suggestions that can help REBT and other cognitive behavioral therapy
(CBT) practitioners adapt their interventions to this population of clients.

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Procedural and Relational Problems with the ABC-DEF

Implementation

Procedural Problems

The first group of problems therapists encounter with PD clients concerns

difficulties in ascertaining the elements of the ABC. As for the A, DiGiuseppe
et al. (2014) identified three problems: clients who have the tendency to report
excessive detail about the A, clients who describe the A in vague and imprecise
terms, and clients who report too many As (DiGiuseppe et al. 2014, pp. 103–106). In
such cases, the authors recommend posing the client with detailed questions, asking
for recent examples of emotional episodes, and avoiding abstract language. A
detailed recording of any antecedent—events, thought, and feelings as well—can
help the client to recognize problematic areas. Vittorio Guidano used a similar
technique and called it ‘‘moviola’’, an Italian word meaning ‘‘slow motion’’ (Dodet
1998). Identifying problematic situations can be difficult for some patients brought
to abstract and intellectualized thinking, since they have the tendency to express
their problems in terms of generic complaints about the world and the others
(DiGiuseppe et al. 2014, p. 249; Vaillant 1992, p. 274).
Even for the task of identifying the C, DiGiuseppe et al. (2014), identified some
possible problems: difficulty expressing emotions, a tendency to hide socially
shameful emotions like anger, and the presence of functional components in
emotions. Guilt and shame about emotions are the most recurring troubles in
identifying the C. For example, anger can be denied because of fears that once
expressed, anger would have a negative impact on social relationships (Di Giuseppe
and Tafrate 2007). On the other hand, clients may acknowledge their anger but find
it extremely difficult to recognize the emotions that anticipate and support anger
such as anxiety related to a fear of abandonment (Dimaggio et al. 2015). In addition,
some clients have difficulties in being aware of their subjective experience (Bach
and Bach 1995) and only report the physiological and/or behavioral component of
their Cs.
The main problem concerning the IBs is the difficulty clients have in
understanding the B–C connection. Even when clients make the connection, it
does not mean that they are able to work on their IBs, although they can recognize
them as irrational. Even when there is an intellectual understanding of the B–C
connection, these clients might continue to regret external events, in particular
interpersonal events, regarding significant others (DiGiuseppe et al. 2014,
pp. 59–64, 134–154; Ellis 1962, p. 19; Sarracino and Dazzi 2007; Shore 2003).
Concerning the D, the disputing of the ABC consists of teaching participants to
recognize and challenge their irrational self-statements (DiGiuseppe et al. 2014,
p. 161–212; Ellis and Grieger 1986). The major problem is that the D is emotionally
and cognitively challenging as it involves changing cherished ideas that the clients
think are helpful. Discussing your own beliefs implies being aware of them,
something which often is difficult for clients with PDs (Beal et al. 1996; DiGiuseppe
et al. p. 249; Dimaggio et al. 2015).

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Clearly, the difficulty in recognizing and accepting the B–C connection and in
engaging in the D of irrational beliefs hampers an effective learning of new beliefs
(E) and the co-construction of more functional emotions and responses (F). This
difficulty, particularly in clients with PDs, might have the paradoxical effect to
strengthen a client’s IBs rather than challenge them. These difficulties in disputing
IBs might show in different ways: such as the rationalizing and ‘‘intellectualizing’’
client and the argumentative (‘‘yes… but’’) client (DiGiuseppe et al. 2014, p. 249).
This dysfunctional attitude takes the form of a continuous engagement in ruminative
thinking style that involves the client in repetitive monitoring on discrepancies
between idealized shoulds and musts and reality (Caselli et al. 2014) and focusing
on negative emotions, mainly depression (Nolen-Hoeksema et al. 2008). In these
cases, the therapist might be involved in a sterile and repetitive discussion on IBs.

Psychotherapeutic Relationship

A second group of problems is related to the question: how REBT’s ABC-DEF

implementation may influence the psychotherapeutic alliance? The therapist-client
relationship in REBT is significantly influenced by typically persistent therapists’
style actively focused on clients’ IBs, compliance with completing homework and
shared faith in the validity of REBT’s philosophy:
From an REBT perspective, there is very little that builds the relationship more
than the client’s leaving the first session believing that he or she has already begun
to be meaningfully helped. Thus, the therapeutic alliance depends on the active
collaboration between client and REBT therapist in helping the client get better and
work toward his or her goals. In this way, REBT therapists utilize the common
factors of the therapeutic alliance as well as the client’s perceptions of early
improvement and the expectations for continued change (MacLaren et al. 2016,
p. 257).
REBT therapists always vehemently and convincingly encourage their clients, an
impassioned version of psychotherapeutic validation. Recommended directly by
Ellis is the REBT psychotherapist’s unconditional acceptance of the client, an
aspect usually associated with Carl Rogers and his nondirective approach.
Moreover, unconditional acceptance, and rationality as a pathway to gain high
frustration tolerance, could be considered among the tenets of a REBT personality
theory (Ziegler 1999, 2000). These principles significantly influence the psy-
chotherapy setting and relationship (DiGiuseppe 2011; Doyle 2011). In addition, the
emphasis on the current here and now functioning of the patient creates a positive
climate for psychotherapeutic work that can foster of a positive relationship in
REBT psychotherapy (Garfield 1995).
REBT’s deductive, hypothesis-driven approach to assessment can build a
therapeutic relationship by demonstrating to clients that therapists are actively
searching to understand and help clients solve their problems, and honestly
collaborating with clients to confirm or disconfirm the therapists’ hypotheses
(DiGiuseppe 1991). By using the Therapy Relationship Questionnaire (Truax and
Carkhuff 1967), DiGiuseppe et al. (1993) found that the active, directive,
hypotheses-driven approach to therapy practiced in REBT can result in a positive

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therapeutic relationship. Therefore, although REBT theory does not maintain that
the relationship is itself curative, a positive relationship in REBT psychotherapy is
frequent, which in turn is influential in producing positive outcomes in therapy
(Garfield 1995). In addition, some studies have shown that in REBT psychother-
apeutic setting is possible to profitably manage personality traits that are usually
troublesome (Dempsey et al. 1994), and that REBT disputing could help ameliorate
the negative behaviors generated by particular adverse personality traits (Blau et al.
2006). Both these studies suggest that the psychotherapeutic relationship of REBT
can be a protected place for clients.

Suggestions from Non-REBT Clinical Literature Applicable to Difficult

ABC-DEF Implementation in Clients with PDs

The scientific literature on PDs, and in particular metacognitive and mentalization

models, has focused on the difficulties of the clients with PDs in identifying
emotions, understanding the causes of their suffering, and realizing that their
unhealthy emotions might affect their dysfunctional behavior.
Mentalization-based treatment (Bateman and Fonagy 2004; Fonagy and Bateman
2006) suggests that the difficulties of PD clients may depend on an instability in
mentalizing (defined as the process by which we implicitly and explicitly interpret
the actions of oneself and others as meaningful on the basis of intentional mental
states). When individuals with PD, and in particular BPD, are symptomatic, this is
associated with mentalizing going ‘‘off-line’’. Prementalistic states arise: clients
experience that their mental states mirror outer reality and are not mere ideas
(psychic equivalence), and that only the actions that have an impact on the physical
world are believed to be able to change their own and other’s states of mind
(teleological stance).
Metacognitive interpersonal therapy (Dimaggio and Lysaker 2015; Dimaggio
et al. 2015) also offers useful insights for understanding the difficulties exhibited by
patients with PDs in recognizing, naming, and reflecting upon their states of mind.
According to the metacognitive interpersonal approach, these clients take their
maladaptive beliefs as true, and are almost unable to see things from different
perspectives, a difficulty that is defined as poor metacognitive differentiation
(Dimaggio et al. 2007, 2015). Furthermore, the ability to use the knowledge about
mental states to reduce suffering and find new solutions to relational dilemmas is
typically deficient in patients with PDs (Carcione et al. 2011; Lysaker et al. 2011).
One problem lies in the difficulty these clients have in being aware of their
subjective experience, something that has been named poor metacognitive
monitoring (Carcione et al. 2011). Such individuals hardly describe specific events
in which they can put their emotional states and arousal in words. They can describe
disturbing experiences in vague and somatic terms (Lo Verde et al. 2012; Taylor
et al. 1997) or use intellectualizations and abstract theories about human functioning
(Dimaggio et al. 2015).
In the absence of a detailed description of a specific event and access to both
emotional experiences and psychological processes linking antecedents, beliefs, and

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emotional/behavioral consequences, it is pointless to question clients’ theories about

the causes of their problems, as these theories only marginally reflect their actual
thought- affective processes. This problem may be related to these clients’ narrative
style (Dimaggio et al. 2012). Clients with PDs often indulge in hyper-generaliza-
tions and intellectualizations, and show a poor access to specific autobiographical
memories (Taylor et al. 2004).
Reduced mentalization and metacognition are key barriers to applying REBT to
challenge IBs. In REBT terms, these difficulties could be described as a tendency of
the client to focus on the A–C connection rather than the B–C—i.e., working on
external conditions and not on beliefs (Ellis 1994). Moreover, these clients insist on
making grandiose demands on themselves, on others, and on life conditions and yet
do not seem to be notably disturbed. Usually, they resort to self-deception,
rationalizing, withdrawal, distraction, addiction, relying on other people’s support,
and lack of self-directedness (Ellis 1997). This leaves the clinician without the
information needed to understand the clients’ irrational beliefs and then to start
disputing them (DiGiuseppe et al. 2014, pp. 59–64, 134–154, p. 249).
These difficulties in making sense of the mental states might present several
obstacles with clients with PDs. The first problem is the tendency of these clients to
hold positive beliefs about their maladaptive beliefs regarding human relationships.
Many such beliefs are coping procedures aimed at protecting the person from
psychological pain or damage related to human relationships. Narcissistic individ-
uals might hold grandiose beliefs as a coping strategy against a sense of inner self-
derogation (Jellema 2000). Patients with paranoia tend to think others are
dangerous, humiliating and malevolent, but this often is a consequence of their
basic sense of inner vulnerability and inability to react to threats effectively
(Dimaggio et al. 2012).
As a result, challenging beliefs related to habitual coping procedures might easily
result in increasing clients’ tendencies to reject the clinician’s interventions, thus
leading to an alliance rupture because of lack of agreement on the tasks of therapy.
Moreover, these coping procedures might elicit a sense of strength and safety in the
client, as we can observe in clients with narcissistic and paranoid PDs (Jellema
2000). In these cases, challenging those ways of thinking might undermine a sense
of self-confidence and strength instead of promoting a more realistic view of the
events (Dimaggio et al. 2012).
A second problem observed in clients with PDs (e.g., in avoidant or dependent
clients), is that these clients tend to think that their safety procedures are the only
affordable strategy to protect themselves from denigration, abandonment, and
psychological pain (Millon 1991). Again, the tendency of these clients is to either
overestimate the risk of negative reactions from others or to underestimate their
ability to bear distress, which might present obstacles to engaging in behavioral
experiments aimed to test their IBs (Dimaggio et al. 2012; Millon 1999; Perris
1999).
A third problem is that the therapy process might be affected by how clients
construct an image of the therapist in their mind according to the client’s
interpersonal schemas. For example, if the clinician tries to convince a patient with
a narcissistic PD that other people are justified in their expressions of needs and

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weaknesses, the client easily might become angry (Jellema 2000). A careful
exploration of personal history can help the clinician connect this emotional
response to the experience of caregivers who showed weaknesses and vulnerabilities
in front of the client’s strive for autonomy and assertion (Ogrodniczuk et al. 2005).
Consider the case of a client having a mother suffering from depression. Any
time the patient attempted to be autonomous, the mother reacted with disinterest and
depression. This might have invalidated the client’s request for autonomy and
success. Therefore, when the clinician challenges the client’s ideas—e.g., demand-
ing to be understood by partners in requests for attention and care—the client might
think that the therapist is supporting the others in hampering his or her own life
goals. Therefore, when others constantly are compared with significant figures ex-
perienced by the client in the past, disputing such beliefs may have a negative
impact on the therapeutic alliance (Dimaggio et al. 2015; Ogrodniczuk et al. 2005).
A fourth problem is that in clients with PDs beliefs are strongly influenced by
affects via bottom-up processes (Dimaggio et al. 2007). Many individuals with PDs,
when entering into negative states, might reject any information coming from
external sources, including the therapist, as they only note mood-congruent
information (Farmer and Chapman 2012; Schooler 2002).
In the next section, we suggest a series of adaptations to make ABC-DEF
implementation easier when faced with clients with PDs who show these kinds of
difficulties. We first describe suggestions coming from the REBT approach and then
offer a series of suggestions from other orientations with the idea that they can help
and enrich the REBT therapist’s repertoire in dealing with PD clients.

Adapting the ABC-DEF Framework to PD Clients Suggestions

from REBT Theory

More Work

In his book devoted to resistant clients, Ellis reviewed his personal clinical
experience with clients who had difficulties with disputation (Ellis 2002). In short,
he conceptualized resistance as depending on excessive fear of loss of control. In
clients’ view, resistance depends on the thought that, if they really would get rid of
their biased beliefs, the consequence would be either concretely awful or
emotionally intolerable. In these cases, Ellis’ main suggestion is to attack directly
the belief of emotional loss of control related to the abandonment of irrational
beliefs. In other words, Ellis proposes a sort of metacognitive disputing that
questions the meta-belief that the abandonment of irrational beliefs brings an awful
loss of control.
Ellis’ second main suggestion is to use, in case of resistance, a stronger and even
more challenging disputing style; in other words, more work (Ellis 2002). There is
the risk that this might not work with clients with PDs. For example, clients with
paranoid PD might react with more intense anger and fear if the therapist tries to
challenge their idea that others are trying to deceive them.

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Changing Disputing Modality or Style

Another tip to use with difficult clients is to adapt the disputing mode (logical,
empirical, functional, or philosophical) or style (didactic, Socratic, metaphoric, and
humorous). If the therapist notes that a logical argument does not work with a
certain client, he or she could move to an empirical or pragmatic disputing mode,
take a more directive style, suggest more concrete examples, or limit the use of
humor if the client is too sensitive. Unfortunately, there are no studies that evaluate
empirically the effectiveness of different disputing strategies with resistant or PD
clients, so in these cases what therapists can do is trust their clinical sensitivity and
common sense (DiGiuseppe et al. 2014, pp. 261–284).

Distinguishing Between Rational Beliefs and Effective New Beliefs

Ellis (2002) was aware that actually clients already have rational beliefs alongside
IBs and some of them have difficulties because they believes the IBs more.
Therefore, disputing IBs and building rational beliefs is not sufficient. In order to
weaken the IBs, DiGiuseppe et al. (2014, p. 214) proposes that, instead of directly
disputing the IB, the therapist may encourage the client to look for an effective new
belief (EB) in which there is still something that the client illogically included in the
IB but that can discriminated. The most typical case is demandingness. Here the
client has created a demand that includes a desire in it. Clients thinks that they
cannot desire without demanding and in the long run end up thinking that
demanding mean desiring (DiGiuseppe et al. 2014, p. 216). Encouraging the client
to practice this discrimination allows to them to understand that stopping their
demanding does not mean stopping their desiring and wanting. They can still want
to pass an exam when they stop thinking that they must pass an exam.

Paradoxical and Reversed Disputing

In some cases, when clients defend their irrational beliefs to the hilt, one option is to
assume the role of the devil’s advocate and bring clients’ irrational ideas to the
extreme—i.e., agreeing that unhealthy emotional suffering is fair and should not be
treated. For example, a therapist might say ‘‘You are right, you are really
incompetent’’ in response to a depressed client who defends his self-disparaging
beliefs (DiGiuseppe et al. 2014, pp. 248–249). Such interventions should be
performed gently and with light irony to convey to the clients that they are directed
to their irrational beliefs and not to themselves as persons.
Again, lacking empirical data on the effectiveness of this sort of intervention, it is
the sensitivity of the clinician that can determine whether this ‘‘shock therapy’’
might be useful and/or desirable with a particular client or be counterproductive.
This intervention is helpful if it is very quickly followed by a reformulation of the
therapy contract, which may sound like, ‘‘We agree you are flawed. But my question
now is: How can the therapy be useful if we take this as a matter of fact? It looks
like the only way that is left is accepting that you are flawed and deciding to live

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accordingly. Is that really what you want?’’. Very often, when offered this
perspective, the client comes with alternative, less self-defeating self-images.

Direct Presentation of the Rational Alternative

Another strategy proposed by the REBT literature with difficult clients is skipping
the disputing phase and moving to the direct presentation of a rational alternative, a
more flexible and adaptive way of dealing with situations. For example, DiGiuseppe
et al. (2014) recommends the widespread use of self-instruction and homework in
such cases, in order to encourage the client to practice with them between sessions,
according to the principles of operant conditioning (Meichenbaum 1985). Many
REBT therapists recommend the direct learning of these new, effective beliefs
(E) to the point that some suggest that the disputing phase could be replaced simply
by the presentation to the client of more flexible and less dogmatic rational beliefs
(Beal et al. 1996).
For example, to challenge the self-downing belief of being a failure, the REBT
therapist might ask the client: ‘‘In thinking of being ‘a complete and irremediable
failure’ and ‘a man who has sometimes failed, like all human beings’, which seems
the most realistic alternative and makes you feel better?’’ (DiGiuseppe et al. 2014,
p. 213). This direct jump to the E has the advantage of circumventing the most
challenging aspects of disputing (DiGiuseppe et al. 2014). The risk, in this case, is
that clients with PD might accept rationally the idea offered by the therapist but
their mood remains completely unchanged, and they continue to feel and act
according to their rigid and negative self-defeating belief.

Let Go of the Rope and Observe

When disputing is difficult or not feasible, and the immediate application of the
orthodox (or ‘‘elegant’’) solution is impossible, both Ellis (2002) and DiGiuseppe
et al. (2014, pp. 248–249) propose to stop trying to convince the client and ‘‘see
what happens.’’ The aim of such intervention is to clarify the real objective of the
session, assuming an exploratory attitude, avoiding explicit disputing of the ABC
and just identifying the A, B, and C without questioning. For example, the therapist
could help the client to be more detailed in the description of the activating event
and in particular of the ‘‘critical A’’ (i.e., the most disturbing aspect of the
problematic situation; Dryden and Branch 2008, p. 87–90).
This focusing strategy encourages the client to be more specific and especially to
assume a less passive and more analytical stance in which the events no longer are
incomprehensible but can be broken down into detailed elements. In other words,
such interventions encourage the client to engage with the ‘‘observing ego’’ and to
reflect on his or her experience instead of his self-defeating and impulsive behavior
(Dryden 2005). We suggest that such interventions should be devised cautiously
with PD clients due to the risk that clients perceive the therapist’s intervention as
not affecting their lives and then drop out from therapy prematurely.

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Psycho-Educational Interventions

When clients have difficulty identifying the nature of their emotions (C), psycho-
education may be strongly suggested (DiGiuseppe et al. 2014, p. 249). It is
important to encourage clients to distinguish between functional and dysfunctional
emotions, urge them to deal with feelings of guilt and/or shame about C, and help
them to distinguish Cs from either As or Bs. This strategy might be preliminary to
the DEF phase and with some resistant and difficult clients might represent, in itself,
a significant therapeutic result. The goal of these strategies is to stimulate clients to
assume an investigative stance, in which, rather than disputing the beliefs, they are
asked to maintain a neutral, non-judgmental attitude. This sort of training of clients
in observing and identifying their ABC might help to develop new points of view
(MacLaren et al. 2016, p. 247).
This is consistent with metacognitive and interpersonal approaches, in which
clients are invited to carefully scrutinize specific autobiographical memories until
aspects of the self that are inconsistent with the maladaptive belief spontaneously
emerge (Dimaggio et al. 2015). For example, a client with dependent PD might
describe herself as inept but then describes moments at work in which she works
with competence and clearly displays signs of confidence and self-efficacy. At that
moment, the therapist can let her note how she is viewing herself from a different
and more benevolent angle than the usual firmly held IBs.

Outflanking Disputation

A further example of modified disputing is what we may call ‘‘outflanking

disputing.’’ This exploratory, indirect strategy might be useful when clients are
strictly identified with their IBs, and direct challenging of an IB might threaten the
working alliance (Ogrodniczuk et al. 2005). This might be especially true when
these beliefs are connected with emotions of anger (Di Giuseppe and Tafrate 2007;
DiGiuseppe et al. 2014, pp. 150–151).
In these cases, we suggest taking a less direct approach, which does not challenge
the core content of the IBs, but how clients attempt to make their beliefs real using
procedural beliefs. For example, a client with a narcissistic PD, in treatment with
one of the authors of this paper, not only believed that he must be excellent, but also
believed that this excellence must be recognized by others from his earliest age as,
in his words, ‘‘happened to Mozart’’. Instead of disputing the demand for excellence
itself, which the therapist sensed would be seen by the client as a destructive
personal attack, the therapist disputed the related but less strongly hold IBs about
how soon an outstanding person must achieve and have others recognized his or her
excellence. Should this excellence be achieved immediately or gradually across
successive steps?
Therefore, in an ‘‘outflanking’’ disputation we challenge a collateral version of
the IB. The assumption is that, by facing a side aspect of a demanding or an
awfulizing thought, the client is encouraged to learn to dispute the core version of
his or her IBs.

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It is plausible that REBT therapists already use an outflanking style when

disputing clients with PDs IBs. For example, we observed a creative example of
outflanking disputation with a client with borderline PD by Ellis himself: ‘‘Although
I teach my clients that rage is almost always self-destructive, I induced one of my
borderline clients to give up all thoughts of killing herself because her arch-rival for
her lover’s affection would certainly live and be deliriously happy. So I encouraged
my client, at least temporarily, to keep and vent her rage against her rival and
thereby motivate herself to live and work for her own happiness.’’ (Ellis 2002,
p. 368).

Suggestions from Non-REBT Literature

Encouraging to Concreteness

In a manner similar to what is done in REBT (Dimaggio et al. 2015, p. 84),

metacognitive interpersonal therapy (Dimaggio et al. 2015) suggests that the client
should be encouraged to be more concrete and to frame accurately the episodes in
time and space (Hermans and Dimaggio 2004; Neymaier 2000). Therapists also
might suspend clients gently but firmly to encourage them to be concrete (Dimaggio
and Attinà 2012; Dimaggio and Lysaker 2015). With such an attitude, as anticipated
earlier, it is easier to note moments in which the client spontaneously assumes a
different perspective on self and others, one he or she did not integrate in her
overarching schemas beforehand. At that point, the work of the clinician is mostly
devoted at making the client keep in mind the different belief she holds and
remember it (for example, using flashcards) after the session.

Validation as an Indirect Form of Disputing

The essential aspect of validation is to communicate to clients that their reactions

are understandable. During validation, therapists express to their clients an
unconditional acceptance and listen carefully to the story of their emotional
difficulties (Linehan 1993; Safran and Muran 2000). From this viewpoint, validation
can be also described as a milder form of dispute. By validating only the emotional
states and never the IBs, therapists convey their distance from the client’s IBs.
Validation is also present in REBT as looking for an effective new belief (EB) in
which there is still something that the client illogically included in the IB but that
can discriminated (DiGiuseppe et al. 2014, pp. 214–216). Ellis’ concept of
unconditional acceptance is also related to Linehan’s validation.
Validation, however, involves the risk of falling in complicity with the client’s
IBs. To avoid this, the rule to follow is to validate the emotion but not the
underlying IBs. There must be no ambiguity about this point. For example, with a
client who has a narcissistic PD and believes that his colleagues devalue him, the
therapist might say, ‘‘I understand that you feel depressed at work as you have a
sense that the environment is unfriendly.’’

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The therapist acknowledges the emotional suffering but explicitly says it is the
client who believes that his colleagues are incompetent, emphasizing the
subjectivity of this thought. A slight emphasis on the way the therapist pronounces
the phrase can emphasize further the cognitive distance between the therapist and
the client. Thanks to this preliminary step, the client might be more willing to
describe other narrative episodes in which the connection between the idea that
others are hostile and a feeling of depression and paralysis appears. Then it can be
easier to dispute this idea, for example, showing to the client that in other
circumstance she might have the resources to cope with her difficulties noting that
some people were hostile but others were friendly.

The Use of Personal Life History in Disputing

Another possible variant for classical REBT disputing is focusing on clients’

personal development and the rooting of their irrational beliefs in difficult parental
and familiar relationships. Guidano and Liotti (1983) formulated a developmental,
constructivist model based on John Bowlby’s attachment theory. This model
assumes that a difficult attachment relationship paves the way for a cognitive
vulnerability to emotional disorders (Bowlby 1988). Schema therapy (Young et al.
2003) also attempts to integrate in a cognitive background the exploration of
irrational beliefs that develop from early self-defeating emotional and cognitive
patterns that developed from childhood and are repeated throughout life.
Lorenzini and Sassaroli (1995) proposed an added layer of developmental
analysis to ABC by simply asking their clients, ‘‘Where did you learn this?’’ after
assessment of the IBs. This simple question encourages the clients to report their
personal history about a particular IB, including the episodes and experiences that
fed it and led to it emerging. The idea is to obtain a stream of retrospective ABCs
that illustrate the client’s rigid and dysfunctional ways coping with the difficult
circumstances experienced in life.
For example, perfectionistic tendencies and a sense of inflated responsibility
might have their developmental roots in early attachment relationships heavily
imbued with coldness, emotional distance, and criticism on the parents’ side. In
short, the therapist encourages clients to switch from a strong adherence to IBs,
assuming a stance in which they lean more to considering their ideas as subjective
thoughts linked to a particular story and being more able to adopt different and more
adaptive perspectives. A similar stance has been adopted in metacognitive
interpersonal therapy for PDs (Dimaggio et al. 2015), which invites clients to
connect recent episodes to past ones to let them pass from a position of ‘‘my belief is
true’’ to one of ‘‘my belief is one I have learned from the person who reared me.’’

Disputing Focused on the Therapeutic Relationship

Clients with PDs frequently show distrust toward themselves, the world, and the
therapist, and therefore have problems in establishing a good therapeutic
relationship and alliance (Lingiardi et al. 2005; Ogrodniczuk et al. 2005; Sarracino
et al. 2014). If we bring the alliance principle to REBT, we get the tenet of

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‘‘informed alliance’’ (Dryden 2005). The therapeutic relationship is a good setting to

show clients that their ideas about themselves and others might not correspond with
reality (DiGiuseppe et al. 1993).
One can use the therapeutic relationship in various ways to promote a critical
distance. The therapist can ask, ‘‘How do you feel I am reacting? Am I doing or
saying something that is giving you the idea that I too could reject, criticize or harm
you?’’ In this way clients are invited to explore the therapist’s mind and confront
their expectations with what the therapist actually is displaying according to her
speech, facial expressions and prosody (Dimaggio et al. 2015). With such a stance,
clients often come to understand that what they expected does not match the
therapist’s actual behavior. In REBT terms, the therapist suggests, in his or her own
person, a sort of metaphoric disputing the clients’ IB. When clients note that their
therapists are reacting differently from expected, a first seed of differentiation has
germinated (Dimaggio and Attinà 2012).
On the other hand, the therapeutic relationship can activate dysfunctional
interpersonal schemas, and a therapist can contribute to triggering and feeding a
dysfunctional interpersonal cycle. The interventions a therapist performs to extricate
him- or herself from this cycle is a chance for the client to be more aware of
interpersonal IBs, mainly demands regarding how other people should ideally think
or behave. If a therapist manages to maintain a cooperative and non-competitive
atmosphere, a client can differentiate other ways to conceive interpersonal
relationships. For example, a client can begin to learn that it is possible to feel
accepted and appreciated even if the relationship is initially based on a lack of
mutual recognition and incomprehension. Thus, a therapist can use what occurs in
session to formulate experiments involving outside relationships. The therapist
might ask, ‘‘Is it possible to recreate similar relational conditions between one
session and the next?’’ or ‘‘Can one try to negotiate and find solutions when there
are misunderstandings, abandonments and mutual hostilities?’’ The techniques
involving differentiation via the therapeutic relationship aim at promoting a true and
proper critical distance from a client’s IBs (‘‘I’ve got a schema, but I realize that
things can be different’’). In this sense, such interventions might be considered
equivalent to implicit, metaphoric, and enacted disputing (Dimaggio et al. 2015).

Strengthening Schema-Discrepant Representations of the Self and Others

During conversation, clients will access healthy self-parts on their own accord or
guided by their therapist. Among the collection of associated memories or in the
descriptions of recent episodes, fragments of episodes or whole memories emerge as
schema-discrepant representations of the self and others (Dimaggio et al. 2015). For
example, a client might describe his or her success in a work situation while actually
feeling inept and unable to be independent when faced with superior and critical
others. In these cases, a useful strategy might be stimulating access to these healthy
schema-discrepant narratives as ‘‘sparkling moments’’ (White and Epson 1990) of
the sessions and pointing them out to the client.
The aim is to identify these narrative episodes before they escape conscious
reflection and to keep them in working memory for as long as possible. Keeping

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these narrative episodes in consciousness can be difficult due to their overwhelming

power over the patient’s schema-dependent images. It is important to note that the
goal of this technique is not directly disputing the degree of truth of clients’ negative
beliefs but to help them discover that in these situations their views of self and
others are different from what they usually think and expect. In REBT terms, a
rational alternative might exist to self-downing. The clients can discover that they
are describing themselves as active and able, accepted and appreciated, and capable
of joy. The therapist should validate this arising state with clear communicational
markers such as tone of voice and posture. The therapist’s emphasis must clearly
convey the sense that what has emerged deserves attention and support, similar to
the emphasis that REBT therapists use when they illustrate an effective new belief
to the client (DiGiuseppe et al. 2014, p. 213).

Experiential Disputing

When disputing is difficult to accomplish for the client, the therapist might try to
encourage the client to directly change either the behavioral or emotional C by
means of relaxation training, exposure interventions, role playing, behavioral
activation, and committed action (for a review of these strategies, see DiGiuseppe
et al. 2014, p. 317). These ‘‘inelegant’’ strategies, however, are also aimed at
changing cognitions. In fact, the client is encouraged to implement a kind of
experiential disputing: ‘‘You have this belief and usually behave accordingly. Try to
behave in a more adaptive way, more consistent with your goals and your values. At
that moment, you will be taken out from your typical negative thoughts, but perhaps
more will emerge. Pay attention to what you feel and think during and after the
behavioral experiment.’’ In this way, the client starts to learn to see things
differently.
This experiential disputing is intrinsic in behavioral experiments and homework,
and is one of the most effective forms of disputing for clients with PDs (Dimaggio
et al. 2015). Noting the difficulties of the client in doing homework is also helpful
because it helps the client realize to what extent his or her beliefs are ubiquitous and
ultimately to focus less on the fact that the world is wrong or threatening.
Strategies aimed at helping the client to directly change the A (such as
assertiveness and social problem solving) may also be devised when these
interventions do not reinforce the A–C connection but help the client to replace
sterile demandingness with an assertive affirmation of his or her objectives and
values on the world.

Implicit Disputing during Acceptance and Mindfulness Interventions

Finally, acceptance and mindfulness interventions might help clients to become

aware of Bs and Cs that interfere with their functioning and to hold a detached and
non-judgmental stance toward the As (Hayes et al. 2011; Williams et al. 2007).
These techniques are extensions of the REBT principle of acceptance, which
advocates acknowledgement that a psychological experience has happened, that it is

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unpleasant, and that the best way to deal with it is to allow it to be until it disappears
(Dryden 2005).
Acceptance is useful not only for its intrinsic therapeutic value, but also for
understanding and coping with a client’s difficulties with the ABC-DEF framework
(Sassaroli et al. 2015). REBT and CBT therapists do not consider acceptance and
direct modification as contradictory concepts but follow the well-established
Niebuhr’s principle of fostering ‘‘the serenity to accept what cannot be changed, the
courage to change what can be changed, and the wisdom to know the one from the
other’’ (cited in Wygal 1940).

Discussion

REBT and non-REBT literature provide a good range of suggestions regarding the
management of clients with PDs who have problems establishing a good working
alliance or who are unwilling and/or unable to change their IBs. We have to be
realistic and cautious about the results we expect with this type of population. In this
regard, we think that the words of Ellis (2002, p. 366) are still true: ‘‘Try for real
improvement but expect limited gains with most of them. Fully accept this reality
and do not discourage yourself when you meet up with it.’’
Expecting unrealistic results in these patients, especially in the more disturbed, is
an ever-present risk for therapists. The principle is to try to change the aggressive,
dysfunctional, and problematic behaviors but basically unconditionally accept the
person as a human being with limitations. Therapists should only rate or evaluate
clients’ thoughts, feelings, and behaviors and not fall into the dangerous error of
rating or measuring the clients themselves, their essence, their being, or their totality
(Ellis 1994, 1997).
This does not mean that these individuals cannot be helped to adopt more
flexible, realistic, and benevolent ideas about themselves and others. Sometimes this
can be obtained with the usual elegant solution and disputing methods of REBT. It
is wise, however, to keep in mind that with such difficult clients, disputing irrational
beliefs is more challenging because they are likely to come up with a variety of
doubts, reservations, and objections to surrendering their irrational beliefs and
acquiring alternative rational beliefs; therapists need to be reserved, and respond
quickly, tactfully, and persuasively to clients’ queries (Dryden 2005, p. 110).
We noted how, with these clients, the traditional REBT disputing might be
insufficient to produce change. Ellis was very attentive to the new cognitive
approaches with these clients (Ellis 1994) and proposed ‘‘to use the kind of
dialectical or oppositional persuasive techniques of Linehan (1993) […] or the
paradoxical and metaphorical methods that Hayes […] uses with agoraphobics but
also that can sometimes be used with borderline personalities’’ (Ellis 2002, p. 368).
REBT therapists have many cognitive, emotional, and behavioral techniques to
use now, so when the usual ones do not work, they might adopt the ones we suggest
here. The next step is to perform process research, such as a session analysis, to
discover the interventions that actually promote change versus the ones that do not

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further increase a client’s unwillingness to change and deteriorate the quality of the
therapeutic relationship.

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