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REBT therapy manual for clinical psychologists...

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COUNSELLING IN A NUTSHELL SERIES edited by Windy Dryden

Rational Emotive Behaviour Therapy in a nutshell

Michael Neenan and Windy Dryden

COUNSELLING IN A NUTSHELL SERIES edited by Windy Dryden

Rational Emotive Behaviour Therapy in a nutshell

COUNSELLING IN A NUTSHELL SERIES edited by Windy Dryden

Rational Emotive Behaviour Therapy in a nutshell

Michael Neenan and Windy Dryden

SAGE Publications London ● Thousand Oaks ● New Delhi

© Michael Neenan and Windy Dryden 2006 First published 2006 Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act, 1988, this publication may be reproduced, stored or transmitted in any form, or by any means, only with the prior permission in writing of the publishers, or in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers. SAGE Publications Ltd 1 Oliver’s Yard 55 City Road London EC1Y 1SP SAGE Publications Inc. 2455 Teller Road Thousand Oaks, California 91320 SAGE Publications India Pvt Ltd B-42, Panchsheel Enclave Post Box 4109 New Delhi 110 017 British Library Cataloguing in Publication data A catalogue record for this book is available from the British Library ISBN 1-4129-0770-5 ISBN 1-4129-0771-3 (pbk) Library of Congress Control Number: 2005932248 Typeset by C&M Digitals (P) Ltd., Chennai, India Printed on paper from sustainable resources Printed in Great Britain by The Cromwell Press Ltd, Trowbridge, Wiltshire

Contents Preface

vi

1

A Basic Overview of REBT

1

2

Assessment

15

3

Disputing

25

4

Homework

40

5

Working Through

55

6

Promoting Self-Change

74

References

84

Index

88

Preface Our aim in this book is to be comprehensively concise, i.e. to cover all of the key elements of REBT theory and practice in as few words as possible. The idea for this book came from our students who wanted a succinct and no-frills introduction to REBT to act as a counterweight to and relief from the lengthy and sometimes complicated texts they are required to read as part of a standard training course in REBT (any ‘frills’ in the book are contained in the notes section at the end of each chapter so as not to clutter up the main body of the text). Reading lengthier REBT books will not be of much use to students in enhancing their knowledge of REBT if they are still struggling to grasp its basics. We hope that this book will ease their struggle. Michael Neenan Windy Dryden

A Basic Overview of REBT

1

Where you are looking is usually where your attention is. When clients come to therapy their attention is usually focused on others or events which they blame for causing their emotional problems. Clients rarely blame their thinking for causing these problems. Rational emotive behaviour therapy (REBT), founded in 1955 by an American psychologist, Albert Ellis, is a system of psychotherapy which teaches individuals that it is their beliefs which are largely responsible for their emotional and behavioural reactions to life events. The cornerstone of REBT is stated by the Stoic philosopher, Epictetus: ‘People are disturbed not by things, but by the view they take of them.’ REBT teaches clients to look inward in order to examine their view of events before turning their attention outward to seek ways of modifying the adverse impact of these events.

The ABCDE Model of Emotional Disturbance and Change This model is the centrepiece of REBT theory and practice. Every problem is placed within the model to teach the client and guide the therapist. In this model: Situation = What has happened, is happening or will happen. Critical A = What the client is most upset about.

iB = irrational beliefs. These beliefs are called irrational because they evaluate the activating event in a rigid and extreme way. C = emotional and behavioural consequences. These disturbed feelings and counterproductive behaviours are largely determined by the client’s irrational beliefs about the event.

Rational Emotive Behaviour Therapy in a Nutshell

D = disputing. This involves challenging or questioning the irrational beliefs at B that largely produce the client’s emotional and behavioural reactions at C. E = a new and effective rational outlook.

It is vital that you teach your clients that B, not A, largely determines C otherwise they will see changing events at A rather than disputing beliefs at D as the solution to their emotional problems. Let us look at an example of the ABCDE model: Situation = ‘I am presenting a workshop next week.’ Critical A = ‘The possibility that my mind will go blank when I’m asked questions and I’ll look stupid in the eyes of the audience.’ iB = ‘My mind must not go blank when I’m asked questions because, if it does, this will prove to the audience that I’m stupid.’ C = anxiety and overpreparation. D = ‘I certainly hope that my mind will not go blank but I cannot guarantee that it won’t or demand that it must not. If it does go blank, this will be due to my nervousness, not because I’m stupid even if the audience think otherwise.’ E = the client now accepts, not fears, the hazards of giving presentations, does not judge himself on the basis of these presentations but only judges his performance which he wants to improve.

2

Rigid and Extreme Beliefs

1 Awfulizing – this refers to defining negative events as so terrible that nothing could be worse and no good could ever possibly come from these events, for example, ‘It’s awful to live alone. I’d rather be dead.’ 2 Low frustration tolerance (LFT) – this is the perceived inability to endure frustration or discomfort in one’s life and envisage any happiness while such conditions exist, for example, ‘I can’t stand being stuck in these bloody traffic jams every day!’ LFT is also referred to as ‘I-can’t-standit-itis’. Walen et al. suggest that LFT ‘is perhaps the main reason that clients do not improve after they have gained an understanding of their disturbance and how they create it’ (1992: 8).

3

A Basic Overview of REBT

REBT hypothesizes that absolute and rigid musts and shoulds are to be found at the core of psychological disturbance.1 For example, the anxiety-inducing belief, ‘I must be certain that I won’t be rejected when I ask her out’ and the anger-creating belief, ‘You absolutely should not disagree with me when I need your support’. Musts and shoulds can be seen as demands we make on ourselves, others and the world. It is important to elicit the meaning of the must or should in order to determine if it is meant in an absolute sense, for example, ‘I must get that promotion’ (the client can conceive of no other outcome) versus ‘I must get that promotion’ (the client wants the promotion very much but realizes and accepts that he might not get it). Pursuing nonmalignant musts can waste valuable therapy time and turn you into what Dawson (1991) calls a ‘mad-dog disputer’, that is, slipping the leash of clinical restraint and attacking every must and should uttered by your clients. Flowing from these rigid musts and shoulds are three major and extreme derivatives.2

Rational Emotive Behaviour Therapy in a Nutshell

3 Depreciation of self, others and life – this involves giving a global negative rating to ourselves or others as if it represents the ‘true self’ and to life as if it is a true representation of life conditions, for example, ‘I didn’t get the job which means I’m a failure’; ‘You’re a bastard for giving me that extra work’; ‘Life is no good for giving me this unfairness.’

These rigid and extreme beliefs are called irrational or selfdefeating because they are illogical (that is, do not make sense), unrealistic, interfere with goal-attainment and largely create and maintain emotional disturbance.

Flexible and Non-Extreme Beliefs Flexible beliefs are based on wishes, wants, preferences and desires, for example, ‘I very much want you to love me but I realize there is no reason why you must love me.’ Flexible beliefs are deemed to be at the core of psychological health and lead to less intense negative feelings rather than disturbed feelings about adverse events, for example, feeling sad rather than depressed about the end of a relationship. Flowing from these flexible beliefs, are three major and non-extreme derivatives. 1 Non-awfulizing – negative events could always be worse even if things are very bad indeed and some good may eventually come from the grimness of present circumstances, for example, ‘I don’t like living alone but maybe I can learn to make it less oppressive.’ 2 High frustration tolerance (HFT) – learning to increase the ability to withstand discomfort and hardship in life and still enjoy some measure of happiness, for example, ‘I can stand

4

Thoughts and Beliefs REBT suggests that there are different levels of cognitive activity that we need to be aware of in understanding emotional disturbance. These levels are:

Inferences These are personally significant assumptions about events that may or may not be true, for example, ‘My partner is going to leave me. I won’t be able to cope living on my own. I have no future.’ Inferences are often linked, as in the example, and these linkages can be revealed by asking, ‘Let’s assume that’s true, then what?’ questions. This process is known as inference chaining and is a major technique for uncovering the client’s critical A, that is, the emotionally hottest part of the situation. Inferences are part of the A in the ABC model. Some therapists may find inference chaining

5

A Basic Overview of REBT

these traffic jams without liking them and, instead of ranting and raving about them, listen to some classical music.’ Acquiring HFT helps clients to achieve their goals by persisting with the hard work that change usually requires. 3 Acceptance of self, others and life – human beings are seen as fallible (imperfect) and in a state of continuous change, so it is futile to give ourselves or others a global rating (either positive or negative) as this can never encompass the totality of what it means to be human, for example, ‘I didn’t get the job but this does not make me a failure’; ‘You’re inconsiderate for giving me that extra work, but you’re not a bastard for doing so.’ Life is seen as a complex mixture of positive, negative and neutral events, for example, ‘This situation is unfair but it does not mean that the whole of life is.’

too difficult to accomplish and, therefore, we would suggest they use a more straightforward way of locating the critical A such as asking the client: ‘What are you most upset about in this situation?’ (for further ways of finding the critical A, see Neenan and Dryden, 1999).

Rational Emotive Behaviour Therapy in a Nutshell

Specific evaluative beliefs These are specific appraisals of our inferences; in other words, we make up our minds about specific situations and deliver judgements. With regard to the above example, the client’s appraisals are: ‘My partner must not leave me. I can’t stand living alone. It’s awful to have no future.’ Evaluative beliefs can also be held at a general level and cover a range of situations, for example, ‘I must have people around me all the time.’ When evaluative beliefs cover a broad range of situations and are at the root of the client’s emotional disturbance, they are known as core beliefs.

Core beliefs These are the central philosophies that shape our view of ourselves, others and the world. Core irrational beliefs (for example, ‘I’m a failure’) can be difficult to detect as they remain dormant during periods of stability in a person’s life. They usually become activated and pass into the person’s awareness at times of emotional stress or upheaval in his life. Core beliefs are the ultimate target of REBT intervention if clients are to achieve what Ellis calls a ‘profound philosophical change’ in their outlook.

Two Types of Disturbance REBT suggests that two types of emotional disturbance underlie most, if not all, neurotic problems: ego and discomfort.3 6

Ego disturbance involves psychological problems related to one’s self-image, for example, feeling depressed about erectile dysfunction, ‘I’m not a real man any more.’ Discomfort disturbance concerns psychological problems related to one’s sense of comfort and discomfort, for example, getting angry about the slowness of a long queue, ‘I can’t stand this situation any longer.’ These two forms of disturbance are separate categories but frequently overlap in clients’ presenting problems. For example, a person condemns himself as ‘weak’ (ego) for getting stressed-out about his high workload (discomfort). In assessing your clients’ problems, you need to be aware that they may have both ego and discomfort aspects to them.

Rational thinking leads to a reduction in the intensity, frequency and duration of emotional disturbance (Walen et al., 1992). Less disturbance usually means more psychological stability. REBT has traditionally distinguished between inappropriate and appropriate emotions (Ellis, 1980) and, more recently, between unhealthy and healthy negative emotions (Dryden, 1995). Inappropriate or unhealthy negative emotions (for example, anxiety, depression) are underpinned by irrational beliefs while appropriate or healthy negative emotions (for example, concern, sadness) are underpinned by rational beliefs. However, to date, there is no research support for the idea of qualitatively different continua of emotions, only for a continuum of emotional intensity.4 Therefore, avoid lecturing clients about or insisting upon these categories; let your clients select the words they wish to use (for example, less worried, calmer, confident, determined) for their emotional goals. The important point is to ascertain if 7

A Basic Overview of REBT

Emotional Change

the emotional goal reflects a self-helping and flexible outlook.

Rational Emotive Behaviour Therapy in a Nutshell

Two Forms of Responsibility The first form is emotional responsibility (not blame) whereby the client accepts that his emotional disturbance is largely self-induced by the irrational beliefs that he holds. The ABC model establishes emotional responsibility: Situation = Client loses his job. Critical A = ‘I can’t see myself as worth anything if I don’t have a job.’ iB = ‘I must have a job because, without one, I’m not worth anything.’ C = depression and withdrawal.

Losing the job is unfortunate, but the client’s depression is determined by his evaluation of himself as worthless, not by losing the job itself. The second form is therapeutic responsibility whereby the client commits himself to the hard work of personal change by disputing his disturbance-creating beliefs and acting in support of his emerging rational beliefs. The D and E elements of the model encourage therapeutic responsibility: D = ‘I’m a man without a job, not a man without worth. A job can be taken away from me, but not my worth unless I allow it to happen.’ E = starts looking for another job – ‘I will persevere until I find one.’

If your clients want to achieve a successful outcome in REBT, then it is vital that they accept both forms of responsibility – ‘I disturb myself’ and ‘I will learn how to undisturb myself’. 8

Maintenance of Emotional Disturbance REBT focuses on how emotional problems are maintained rather than how they were acquired. Irrational ideas are the central means of maintaining these problems. While exploring the past is not neglected in REBT, it is not seen as crucial in order to help your clients with their current difficulties:

The past can be viewed through the lens of the present, for example, ‘Your father told you that you would always be a failure. Do you continue to believe that yourself?’ Ideas that may have originated in the past are owned and maintained by the client in the present.

Elegant and Inelegant Change Elegant REBT involves clients undergoing a profound philosophical change by surrendering all their rigid musts and shoulds and their extreme derivatives: ‘If people had a truly sound philosophy, they could ward off practically all neurotic thinking, feeling and behaving and arrange their lives so that they would rarely, if ever, be self-defeating and 9

A Basic Overview of REBT

Human emotional problems do not result from the experiences people have, whether these experiences are historical or current, but from the way people interpret and continue to interpret these experiences. When a person is emotionally disturbed, the disturbance results from a currently held way of thinking and believing. (Grieger and Boyd, 1980: 76)

Rational Emotive Behaviour Therapy in a Nutshell

antisocial’ (Ellis, 1991: 8–9). In our experience, the majority of clients that we see are not interested in this kind of philosophical change but more modest cognitive or so-called inelegant change (for example, reframing negative events in a positive light, less catastrophizing, greater self-acceptance). It is important that you do not indicate to your clients that the inelegant solution is the inferior solution (how many REBT therapists truly embrace the elegant solution in their own life?). Discuss REBT’s concept of philosophical change but work on the change the client wants, not what you think she should be working on.5

Helping Clients to Get Better and Not Just Feel Better Clients can usually feel better through the services of a warm and caring therapist but getting better would be confronting those situations in which they disturb themselves. For example, the therapist might tell her client that he is a worthwhile human being who has a lot to offer to others despite recent rejections and he feels better on hearing this; getting better would be the client believing this himself rather than relying on others to tell him and accepting himself in the face of further rejection. Feeling better is usually short-lived while getting better is longer-lasting (Ellis, 1994).

Relapse Prevention This strategy teaches clients how to reduce the occurrence of future episodes of emotional disturbance (we do not become permanently undisturbable). When these episodes do occur, clients are instructed to deal with them as quickly

10

as possible to minimize the chances of a lapse (a partial return to a problem state) turning into a relapse (a full return to a problem state). If clients do slide back into emotional disturbance, Ellis (1984) advises clients to ‘look for the must, look for the absolute should’ that has re-entered their thinking. Relapse prevention strategies are taught during the last few sessions of REBT.

Active-Directive Style

11

A Basic Overview of REBT

This involves you actively guiding clients to the salient aspects of their presenting problems and is deemed to be more effective in helping clients change than a passive or non-directive style of intervention. REBT therapists are active in, inter alia, asking questions, forming hypotheses, collecting assessment data, limiting extraneous material or client rambling, problem-defining, goal-setting, teaching, disputing beliefs and negotiating homework tasks – all these and other activities are aimed at directing clients’ attention to the hypothesized cognitive core (that is, rigid musts and extreme derivatives) of their...