Randall D. Ordovich Clarkson, MD
May 7, 2022
Introduction to Rational Emotive Behavioral Theory
Rational Emotive Behavioral Theory (#REBT) was developed by Albert #Ellis as a way to provide an alternative to #psychoanalytic theory in an effort to, “dispensed with the slow, laborious methods such as free association and dream analysis” (Murdock, 2017, p. 269). One of the key principles of REBT is that we have the ability to change the perception of noxious stimuli in our lives, thereby reducing the latter’s impact on our emotional state. Ellis’s model involves the basic principle of ABCs, where A represents an activating event, where B represents the beliefs about A, and where C represents the consequences of adhering to B (Dryden, 2005). In other words, in the therapeutic setting, one seeks to change the beliefs of the activating event in order to change the ultimate consequences both emotionally and environmentally. Additionally, many beliefs, according to Ellis’s model, are fundamentally irrational, hereby referred to as #Irrational Beliefs (IBs) (Sarracino, 2015). According to REBT, these IBs can be altered throughout the therapeutic process. In order to change the patient’s ABCs, the therapist can help establish the DEFs, with D representing the disputation of the aforementioned ABCs, where E represents effective adoption of new beliefs, and where F represents the implementation of functional emotions and responses to achieve greater mental balance (Sarracino, 2015). In this article, we will discuss the methods, techniques, and beneficial outcomes of implementing REBT as they relate to a fictitious patient Mrs. A. and her presenting problem.
...many beliefs, according to Ellis’s model, are fundamentally irrational...referred to as Irrational Beliefs (IBs)
Counseling Goals and Intervention Strategies
During the process of adjusting one’s ABCs and adopting healthier DEFs, one must undergo several different stages. According to Dryden (2005), there are a number of goals in REBT which include the following:
Understand that we create our own psychological problems. Challenging situations will always contribute to these problems; however, these are an aspect of life’s ‘change process’
Recognize that we are able to address and overcome life’s problems through healthy restructuring of our approach
Many of our problems stem from IBs
Identify our IBs and set them apart from our rational beliefs
Question IBs until we understand them to be false and unconstructive, and thereby identifying with rational beliefs which are beneficial and constructive
Internalize rational beliefs through the use of cognitive techniques, including emotive and behavioral changes
Implement these techniques to other areas of one’s life in order to benefit one’s emotional state
In addition to the aforementioned goals, REBT involves changing perception of noxious stimuli through the concept of ABCs and DEFs:
A) The Activating event
B) Beliefs about the Activating event
C) Consequences of adhering to stated Beliefs (Dryden, 2005)
D) Disputation of the ABCs
E) Effective adoption of new beliefs
F) Functional emotions and responses
Let us consider a fictitious vignette involving Mrs. A., a 25 year old patient from Guatemala, who is fluent in both English and Spanish. Mrs. A. presents with a recent job loss, feelings of hopelessness, weight-loss of 10 pounds over 2 months and concerns of becoming homeless. She is married with a young child; however, her husband is in the military and is currently on deployment. Upon initial evaluation, Mrs. A. is tearful, states she is anxious and depressed, avoids eye contact, and has a flat affect. Having completed 1 year of college, she worked as a banker; though she was furloughed three months ago. Despite coming from an affluent family in Guatemala, she refuses to ask them for financial assistance. She has 4 siblings all of which graduated college with professional careers. Mrs. A. states that she is 'close' to her family although she has not seen them for a year. Her father is a banker and a 'heavy drinker.' Her mother works as an educator. Both her parents have been married for 27 years. Mrs. A. states that she feels alone and overwhelmed, having to raise her 1-year old daughter alone. The patient commits to 8 sessions of psychotherapy.
We can begin by acknowledging that Mrs. A. is doing the right thing by seeking out therapy to overcome her severe psychological hang-ups. She clearly understands her need to seek treatment in the face of her recent stressors. Because of her recent job loss, she is experiencing catastrophic thinking with the belief that she will never recover and ultimately become homeless. Arguably the most important factor in Mrs. A.’s situation is her complete lack of social support from both her husband (who has deployed abroad with the U.S. military) and her family who she has not communicated with in approximately one year. These factors are resulting in significant distress, including weight loss of 10 pounds in two months, along with depressive and anxious symptoms stemming from financial insecurity and the stress of raising a baby by herself. Mrs. A. would likely benefit from several aspects of REBT, particularly in the realm of re-framing her perceptions of the primary noxious stimuli—her recent job loss.
Ellis’s REBT techniques were designed to specifically overcome anxious, self-defeating thoughts and behaviors. Unlike many other therapeutic techniques, REBT is active, forcefully helping clients arrive at unconditional self-acceptance (Murdock, 2017). In Mrs. A.’s therapeutic sessions, the therapist would begin by exploring the A representing adversity or anything problematic. In Mrs. A.’s case, her primary A would be the recent job loss and the subsequent Adjustment Disorder (AjD). Using Ellis’s disputing technique, the therapist would discuss the client’s A, assuming it is true, and explore the psychological underpinnings of said beliefs. Clearly, Mrs. A.’s emotional reaction is a perfectly natural response to the fear of loss, particularly considering that she has little to no social support. According to a study by Lorenz et al. (2018), “Higher loneliness, higher dysfunctional disclosure, and lower self-efficacy were associated with both higher symptom severity and higher likelihood of meeting the diagnostic criteria for AjD.” With Mrs. A.’s lack of social support, and the recent stress resulting from economic uncertainty, she certainly fits the criteria for AjD.
REBT is active, forcefully helping clients arrive at unconditional self-acceptance
The next step would be to explore Mrs. A.’s beliefs about A. At this time, Mrs. A. believes that she will inevitably lose everything, becoming homeless as a result of her job loss. Interestingly, Mrs. A. is the only one of her siblings who did not complete her college education. Furthermore, her parents are successful professionals. As a result, Mrs. A. is likely experiencing feelings of inadequacy, being unable to take care of her family independently while comparing her professional status with both her siblings and her parents. Furthermore, although Mrs. A. states that she has a “close” relationship with her family, she has been out of contact with them for a year. This will be an important belief of hers to explore, considering that she may be in denial of her familial connectivity. Thirdly, the therapist would have to identify the consequences of Mrs. A.’s beliefs. At the present moment, Mrs. A. is adhering to the belief of inevitable failure and the impossibility of obtaining a new professional position. In identifying the Cs of Mrs. A.’s Bs, she may become aware of the fact that these Bs are resulting in crippling distress, which will ultimately impede in her ability to get back on track with her life’s goals.
Although the primary goal of REBT is to replace IBs with rational beliefs through several therapeutic modalities (e.g. cognitive, emotive, and behavioral approaches), REBT can also integrate a solution-focused approach, emphasizing the patient’s strengths and overcoming their deficits (Guterman & Rudes, 2005). In that, the therapist can help Mrs. A. dispute her IBs, represented by D in Ellis’s ABC-DEF approach. Mrs. A.’s primary IB consists of inevitable failure and subsequent homelessness. In disputing this, the therapist can help to motivate Mrs. A. in both finding a new career bath and establishing stronger connections with her family. This process would be in keeping with REBT’s tenant that we are able to overcome obstacles in our lives. Next, Mrs. A. would be encouraged to effectively adopt these new beliefs and to finally implement these functional emotions and responses to her current state.
Process of Treatment
In terms of duration, Ellis felt that, “normal neurotic” clients could improve within 20 sessions (Murdock, 2017, p. 283). Despite Ellis’s sentiments, sessions in the REBT model may vary depending on the severity of symptoms. In Mrs. A.’s case, her symptoms of anxiety and depression secondary to her AjD are very severe, resulting in significant weight loss and emotional distress. The therapist, therefore, would have to work with Mrs. A. for as long as it takes, helping her reframe her negative, self-defeating perceptions and to better cope with her intense catastrophic thought process.
During therapeutic sessions, the therapist will be supportive in their guidance with Mrs. A.. One primary objective in REBT is unconditional self-acceptance; thus, Mrs. A. will have to learn to accept herself as an imperfect human, failing the idealized version of herself (Murdock, 2017). This idealized self would best be represented as a self-sufficient, independent, and successful mother. Also, Mrs. A. will have to think beyond her current obstacles and consider her future in a positive light. According to Ellis (2005), such positive goals include the pursuit of long-range hedonism, which in Mrs. A.’s case would involve her ability to obtain a new successful career in order to satisfy her financial needs. The therapist will also need to help Mrs. A. understand that her lack of social support is contributing to her distress. For instance, Ellis (2005) states that social interest and flexibility and openness to change are fundamental in establishing mental wellbeing.
In seeking these professional and social/familial goals, Mrs. A. needs to become aware of her resistance to reaching out to her family. There, of course, are many aspects at play in this avoidance behavior. First, her relationship with her father may have been negatively impacted by his alcoholism. Secondly, she may feel a sense of inadequacy in the face of her sibling’s academic and professional success. However, if this were the case, these would be deemed IBs, as she has not expressed any explicit judgments imposed on her by family members. In re-establishing contact with her family, she may not only address her financial needs, but also the caring of her baby.
Social and Cultural Needs of the Client
In terms of social and cultural needs, REBT can help Mrs. A. address both her relationship with her seemingly estranged family and also explore her beliefs around her being a first-generation immigrant from Guatemala. In a study on Asian immigrants, Tewary et al. (2012) opines that, “certain vulnerable ethnic minorities [are] at greater risk of ongoing mental disorders and accompanying disruption in their productive lives.” The authors further suggest that these emotional disturbances could be due to depression resulting from possible identity crisis as well as imbalances of, “family hierarchy, gender, roles, and high academic standards in the dominant culture.” Such isolation from one’s cultures of origin can result in a lack of social cohesion, which may result in distress particularly from individuals with collectivistic cultural backgrounds (Tewary et al., 2012). Hence, it would be imperative for the therapist in Mrs. A.’s case to encourage her to reconnect with her Guatemalan family, despite her potential insecurities.
Role of Choice and Decision Making
As stated by Epectitus, “It's not what happens to you, but how you react to it that matters” (Epectitus Quotes, n.d.). Albert Ellis also had a similar response to his patients. For example, a patient of his said that someone made them “feel” a certain way, to which he responded, “That’s really impossible. No one can make you feel almost anything—except with a baseball bat” (Ellis, 2002, p. 110). One of the main goals of REBT is to choose a different perspective of one’s activating events (A), understanding that our beliefs may be fundamentally irrational. This is often the case, for humans are extremely resilient and can undergo enormous change and transformation when necessary. This ability to change is also in keeping with the principle edicts of REBT. Once the patient can finally identify their IBs, they can then choose to dispute (D) their perceptions, which will ultimately change the consequences of their beliefs, thereby resulting in the patient’s E (effective adoption of new beliefs) and F (functional emotions and responses to the activating event) (Sarracino, 2015).
"No one can make you feel almost anything—except with a baseball bat" (Ellis, 2002, p. 110)
Cognitive Processes
As the oldest form of cognitive therapy, REBT is well suited to help patients improve their cognitive processes (David, 2003). By helping Mrs. A. establish rational beliefs, the therapist may help transform her emotional, behavioral, and cognitive consequences. As explained by David (2003), “Cognitive psychology is concerned with the human mind, how it processes information it receives (inputs), and how it develops responses (outputs).” One can argue that therapeutic model of REBT can have enormous consequences in the patient’s life, therefore one must be cautious to not inadvertently cause harm in the treatment process.
In that, the therapist must adhere to the Hippocratic Oath of “primum non nocere,” translated as “First do no harm” and classically written as “I will keep them from harm and injustice” (Hughes, 2007; Tyson, 2001). As Hughes (2007) argues, “Prevention of injury and illness is [a] significant aspect of medical practice.” By adhering to the guidelines set forth by the ACA Code of Ethics, the therapist may reduce the likelihood of committing harm. For example, ACA (2014) states that the therapist must avoid imposing their personal values onto their client. Instead, the therapist needs to do their best to operate within the moral framework of the patient, encouraging the patient to improve their mental wellbeing within their own worldview. In Mrs. A.’s case, for instance, she may be hesitant to adopt the therapist’s belief that her familial connections must be re-established to improve her support network. If challenging situations such as this should arise, the therapist can tactfully explore the root of these cognitive processes, making sure to uphold both patient autonomy and therapeutic rapport.
Conclusion
In that, the therapist must adhere to the Hippocratic Oath of “primum non nocere,” translated as “First do no harm” and classically written as “I will keep them from harm and injustice” (Hughes, 2007; Tyson, 2001). As Hughes (2007) argues, “Prevention of injury and illness is [a] significant aspect of medical practice.” By adhering to the guidelines set forth by the ACA Code of Ethics, the therapist may reduce the likelihood of committing harm. For example, ACA (2014) states that the therapist must avoid imposing their personal values onto their client. Instead, the therapist needs to do their best to operate within the moral framework of the patient, encouraging the patient to improve their mental well-being within their own worldview. In Mrs. A.’s case, for instance, she may be hesitant to adopt the therapist’s belief that her familial connections must be re-established to improve her support network. If challenging situations such as this should arise, the therapist can tactfully explore the root of these cognitive processes, making sure to uphold both patient autonomy and therapeutic rapport.
References
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Sarracino, D., Dimaggio, G., Ibrahim, R., Popolo, R., Sassaroli, S., & Ruggiero, G. M. (2017). When REBT goes difficult: applying ABC-DEF to personality disorders. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 35(3), 278-295. https://doi.org/10.1007/s10942-016-0258-7
Tewary, S., Jani, N., & Anstadt, S. P. (2012). Cognitive behavior therapy: A potential treatment for depression among Asian Indian Immigrant women in the United States. Journal of human behavior in the social environment, 22(4), 463-478. https://doi.org/10.1080/10911359.2012.664980
Tyson, P. (2001, March 27). The Hippocratic Oath Today. Retrieved September 02, 2020, from https://www.pbs.org/wgbh/nova/article/hippocratic-oath-today/