Rational Emotive Behaviour Therapy

Downloaded by [New York University] at 06:45 14 August 2016 Rational Emotive Behaviour Therapy

Rational emotive behaviour therapy (REBT) encourages the client to focus on their emotional problems in order to understand and change the irrational beliefs that underpin these problems. Following on from the success of the rst edition, this accessible guide introduces the reader to REBT while indicating how it is different from other approaches within the cognitive behavioural therapy spectrum. D ivided into two sections, The Distinctive Theoretical Features of REBT and The Distinctive Practical Features of REBT, this book presents concise information in 30 key points. Updated throughout, this new edition of Rational Emotive Behaviour Therapy: Distinc- tive Features will be invaluable to both experienced clinicians and those new to the eld.

Windy Dryden is in full-time clinical and consultative practice and is an international authority on rational emotive behaviour therapy (REBT). He has worked in psychotherapy for more than 40 years and is the author and editor of over 200 books. Downloaded by [New York University] at 06:45 14 August 2016 C o gnitive behaviour therapy (CBT) occupies a central position in the move towards evidence-based practice and is frequently used in the clinical environment. Yet there is no one universal approach to CBT and clinicians speak of rst-, second- and even third-wave approaches.

This series provides straightforward, accessible guides to a number of CBT methods, clarifying the distinctive features of each approach. The series editor, Windy Dryden successfully brings together experts from each discipline to summarize the 30 main aspects of their approach divided into theoretical and practical features.

The CBT Distinctive Features Series will be essential reading for psycho- therapists, counsellors, and psychologists of all orientations who want to learn more about the range of new and developing cognitive behaviour approaches.

Titles in the series: A Transdiagnostic Approach to CBT using Method of Levels Therapyy by Warren Mansell, Timothy A. Carey and Sara J. Tai Acceptance and Commitment Therapy by Paul E. Flaxman, J.T. Blackledge and Frank W. Bond Beck’s Cognitive Therapy by Frank Wills Behavioural Activation b y Jonathan W. Kanter, Andrew M. Busch and Laura C. Rusch CBASP as a Distinctive Treatment for Persistent Depressive Disorderr by James P. McCullough, Jr., Elisabeth Schramm and J. Kim Penberthy Compassion Focused Therapy by Paul Gilbert Constructivist Psychotherapy by Robert A. Neimeyer Dialectical Behaviour Therapy by Michaela A. Swales and Heidi L. Heard Functional Analytic Psychotherapy b y Mavis Tsai, Robert J. Kohlenberg, Jonathan W. Kanter, Gareth I. Holman and Mary Plummer Loudon Metacognitive Therapy by Peter Fisher and Adrian Wells Mindfulness-Based Cognitive Therapy by Rebecca Crane Narrative CBT by John Rhodes Downloaded by [New York University] at 06:45 14 August 2016 Rational Emotive Behaviour Therapy by Windy Dryden R ational Emotive Behaviour Therapy 2nd Edition by Windy Dryden Schema Therapy by Eshkol Rafaeli, David P. Bernstein and Jeffrey Young

For further information about this series please visit www.routledgementalhealth.com/cbt-distinctive-features Rational Emotive Behaviour Therapy

Distinctive Features

Second Edition

Windy Dryden Downloaded by [New York University] at 06:45 14 August 2016 Second edition published 2015 by Routledge 27 Church Road, Hove, East Sussex BN3 2FA

and by Routledge 711 Third Avenue, New York, NY 10017

Routledge is an imprint of the Taylor & Francis Group, an informa business

The right of Windy Dryden to be identifified as author of this work has been asserted by him in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers.

First edition published by Routledge 2009

Trademark notice : Product or corporate names may be trademarks or registered trademarks, and are used only for identifification and explanation without intent to infringe.

British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library

Library of Congress Cataloging in Publication Data Dryden, Windy, author. Rational emotive behaviour therapy. Distinctive features / Windy Dryden. – 2nd edition. p. ; cm. Distinctive features Includes bibliographical references and index. I. Title. II. Title: Distinctive features. [DNLM: 1. Psychotherapy, Rational-Emotive–methods. 2. Behavior Therapy–methods. 3. Emotions. WM 420.5.P8] RC489.B4 616.89’142–dc23 2014026993

Downloaded by [New York University] at 06:45 14 August 2016 ISBN: 978-1-138-80454-8 (hbk) ISBN: 978-1-138-80455-5 (pbk) ISBN: 978-1-315-74943-3 (ebk)

Typeset in Times by Cenveo Publisher Services This book is dedicated to the lives and legacies of Dr Albert Ellis (1913–2004), the founder of REBT and my good friend Dr Arnold Lazarus (1932–2013), the founder of multimodal therapy Downloaded by [New York University] at 06:45 14 August 2016 This page intentionally left blank Downloaded by [New York University] at 06:45 14 August 2016 Contents

Introduction ix List of abbreviations xi List of figures and tables xiii

Part 1 THE DISTINCTIVE THEORETICAL FEATURES OF REBT 1 1 Post-modern relativism 3 2 REBT’s position on human nature and other theoretical emphases: Distinctiveness in the mix 5 3 REBT’s distinctive ABC model 15 4 Irrational beliefs are at the core of psychological disturbance 17 5 Rational beliefs are at the core of psychological health 23 6 Distinction between unhealthy negative emotions (UNEs) and healthy negative emotions (HNEs) 31 7 REBT’s key principle of emotional responsibility 35 8 Explaining why clients’ inferences are highly distorted 39 9 Position on human worth 41 10 Distinction between ego and discomfort disturbance and health 45 11 Focus on meta-psychological disturbance 55 12 The biological basis of human irrationality 63

Downloaded by [New York University] at 06:45 14 August 2016 13 REBT’s position on the origin and maintenance of psychological problems 69 14 REBT’s position on psychological change 71 15 Position on good mental health 73

vii CONTENTS

Part 2 THE DISTINCTIVE PRACTICAL FEATURES OF REBT 77 16 The therapeutic relationship in REBT 79 17 Position on case formulation 83 18 Psycho-educational emphasis 87 19 Dealing with problems in order: (i) Disturbance; (ii) Dissatisfaction; (iii) Development 91 20 Early focus on irrational beliefs (iBs) 95 21 Helping clients to change their irrational beliefs to rational beliefs 97 22 Variety of therapeutic styles 101 23 REBT encourages clients to seek adversity when carrying out homework assignments, but does so sensibly 107 24 Change is hard work and the use of therapist force and energy 111 25 Emphasis on teaching clients general rational philosophies and encouraging them to make a profound philosophic change 115 26 Compromises in therapeutic change 119 27 When to use a change-based focus (CBF) and when to use an acceptance-based focus (ABF) 123 28 Focus on clients’ misconceptions, doubts, reservations, and objections to REBT 125 29 Therapeutic effifi ciency 131 30 Theoretically consistent eclecticism 135

References 139 Index 145 Downloaded by [New York University] at 06:45 14 August 2016

viii Introduction

At the time of writing (November 2013), the cognitive-behaviour therapies are in the ascendancy in the psychotherapeutic spectrum. CBT approaches are the most commonly cited among evidence- based treatments and, in Britain, the National Institute for Health and Clinical Excellence (NICE) recommends CBT more often than other therapeutic approaches in the treatment of a variety of psychological disorders. And yet, within the broad CBT spectrum, there exist a number of approaches that include the so-called rst-wave, second-wave and now third-wave CBT-based therapies. Thus, to say that all CBT therapies are equivalent places too much emphasis on their similarities and too little on their differences. Over a quarter of a century ago, Ellis (1980a ) addressed the issue of the place of REBT in the larger CBT spectrum by distinguishing between two types of REBT. The rst, variously known as specialized or “elegant” REBT focused on the features that Ellis and other leading (past and present) REBT writers (e.g. Dryden, 2002; Grieger and Boyd, 1980 ; Wessler and Wessler, 1980 ) regard as preferential in the treatment of a variety of psychological disorders. The second, variously known as general and the more pejorative “inelegant” REBT was regarded by Ellis as synonymous with the broader eld of CBT so that anything that falls under the rubric of CBT can be regarded as (general) REBT. REBT therapists have privately recognized that specialized REBT, which will be discussed in this book, has its limits, although a full examination of these limits and the conditions under which its effectiveness is questioned has not been fully discussed in the clini-

Downloaded by [New York University] at 06:45 14 August 2016 cal REBT literature, let alone been the subject of empirical enquiry. The fact that REBT can straddle two areas, its speci c area and the wider CBT area, can be seen as having great pragmatic value. Thus, when it suits, REBT therapists can emphasize speci c REBT and when it suits they can also claim that general REBT is really

ix INTRODUCTION

identical with CBT, thus allowing REBT therapists to align themselves with the great advantages of practising an evidence-based CBT approach. The issue of there being two REBTs recently surfaced in the after- math of events at the Albert Ellis Institute, which led to the founder’s disengagement from the Institute that bore his name. Among the very many issues that this very sad situation raised were concerns about what constitutes REBT and the position of the Albert Ellis Institute with respect to how it described its training and clinical services. In this respect, complaints were made that AEI had “watered down” REBT in the Institute’s training and clinical programmes. Observers on the relevant internet discussion boards noted at the time that the Institute’s website on various occasions mentioned REBT and CBT together, sometimes reversing this order. These events and contexts called for a re-evaluation of the distinctive nature of REBT, which I have carried out here. Please note that in the present work, I will concern myself with the distinctive features of speci c REBT. Thus when I use the term “REBT” in this book, I refer to speci c REBT (unless stated otherwise). In doing so, it is hoped that this will stimulate research to be carried out on the major theoretical and clinical hypotheses derived from (speci c) REBT as well as on its therapeutic effectiveness.

W indy Dryden, November 2013 L ondon and Eastbourne Downloaded by [New York University] at 06:45 14 August 2016

x Abbreviations

ABF acceptance-based focus AEI Albert Ellis Institute CBF change-based focus C B T c o gnitive behaviour therapy FHB fallible human being GMH good mental health G S T general semantics theory HNE healthy negative emotions HPE healthy positive emotion s iB irrational belief LD life-depreciation N I CE National Institute for Health and Clinical Excellence OD other-depreciation REBT rational emotive behaviour therapy RET rational emotive therapy S D s e lf-depreciation ULA unconditional life-acceptance UNE unhealthy negative emotion UOA unconditional other-acceptance UPCP understanding the person in the context of his problems UPE unhealthy positive emotion USA unconditional self-acceptance Downloaded by [New York University] at 06:45 14 August 2016

xi This page intentionally left blank Downloaded by [New York University] at 06:45 14 August 2016 List of fi gures and tables

Figure 2.1 REBT’s position on the nine basic assumptions concerning human nature (shaded areas indicate the degree to which REBT favours one of the two human bipolar extremes) Reprinted with permission from Ziegler (2000) F i gure 10.1 The 3 × 2 disturbance matrix F i gure 10.2 The 3 × 2 health matrix Table 6.1 Unhealthy negative emotions (UNEs) and healthy negative emotions (HNEs) in REBT theory Source: Dryden (2002) Table 21.1 Irrational and rational beliefs in REBT theory Downloaded by [New York University] at 06:45 14 August 2016

xiii This page intentionally left blank Downloaded by [New York University] at 06:45 14 August 2016 Part 1

THE DISTINCTIVE THEORETICAL FEATURES OF REBT Downloaded by [New York University] at 06:45 14 August 2016 This page intentionally left blank Downloaded by [New York University] at 06:45 14 August 2016 POST-MODERN RELATIVISM 1

Post-modern relativism

Rational emotive behaviour therapy (REBT) is largely and distinctively based on the major principles of post-modernism and relativism. Enshrined in these principles is the major idea that there is no absolute truth and that so-called “reality” has to be viewed and understood within the context in which it occurs. However, this does not mean that all constructions are deemed to be equal; indeed, far from it. What it does mean is that people need to be sceptical of accounts of phenomena since the account may say as much or in some cases more about the account giver than about the account given. T his is an important point for therapists. Clients will often give an account of an experience and may invite therapists to validate the accuracy of their way of viewing the relevant event as well as how they felt about the event. REBT therapists do not initially get involved in discussions of the accuracy or otherwise of clients’ perceptions and interpretations, preferring to encourage clients to assume temporarily that their interpretations are correct so to identify their beliefs about the said event. The beliefs are deemed to be more in uential in determining their emotional responses to the events than their interpretations. What REBT therapists are in effect saying here is that there may be different ways of viewing what happened to you and it may not be possible or even relevant to discover the truth of what happened to you. So, let’s not get caught up in the pursuit of absolute truth and instead assume, at least temporarily, that you were correct in your views so we can help you to identify Downloaded by [New York University] at 06:45 14 August 2016 and deal with the beliefs about what you think happened to you since these beliefs (as we will see) are of prime importance in explaining your response to this event. When REBT therapists do address the issues of the truth or otherwise of their clients’ interpretations of “reality” (and we tend to do

3 RATIONAL EMOTIVE BEHAVIOUR THERAPY

this after we have helped them to identify and deal with the rigid and extreme beliefs that lie, according to REBT, at the core of their responses), we encourage them to test their interpretations against the available data (as do therapists from Beck’s cognitive therapy). In doing so, we further encourage them to accept as “true” the interpretation that has most supporting data. This is known as the probabilistic approach because we are encouraging clients to accept the interpretation or hunch that is “true” on probabilistic grounds. If this interpretation were a horse in a race, it would be the favourite. How- ever, and this is why this analogy that I have chosen is a good one, REBT therapists recognize that favourites do not always win races and that sometimes rank outsiders can win. Thus, while we encourage clients to accept as “probably true” the interpretation of an experience that has the most supportive evidence, we recognize and teach our clients to recognize that we and they may well be wrong and that a more fanciful hunch may better explain what happened. Yet, often it is not possible to tell. For these reasons, REBT therapists are not as interested in what happened to their clients as they are in their clients’ beliefs about what they think happened to them. REBT also holds a relativistic position about itself and its own propositions. Thus, it holds that its positions may have validity, but not in any absolutistic sense and that these ideas do have to be viewed within context. Its ideas may prove false in the years to come. It is interesting to note, therefore, that in the same way that REBT therapists encourage their clients to take themselves and their lives seriously, but not too seriously, they adopt the same attitude to REBT itself! (see Dryden and Neenan, 2014 ). T he philosophy enshrined in post-modern relativism is nicely encapsulated in the following quote by Jacques Barzun ( 1964 : 184):

Let us face a pluralistic world in which there are no universal

Downloaded by [New York University] at 06:45 14 August 2016 churches, no single remedy for all diseases, no one way to teach or write or sing, no magic diet, no world poets, and no chosen races, but only the wretched and wonderfully diversii ed human race.

4 REBT’S POSITION ON HUMAN NATURE 2

REBT’s position on human nature and other theoretical emphases: Distinctiveness in the mix

As Hjelle and Ziegler (1992 ) have argued, all personality theories are based on assumptions about human nature. REBT is based on a theory of personality that Ellis (1978 ) rst outlined at the end of the 1970s. In this chapter, I will outline REBT’s position on the basic assumptions about human nature underpinning its personality theory. I will also consider REBT’s position on a range of philosophi- cal and theoretical ideas other than that of post-modern relativism, which I discussed in Cha pter 1. REBT’s distinctiveness is not to be seen in any one of its following positions. Rather, its distinctiveness resides in their mix.

REBT’s basic assumptions about human nature: Ziegler’s approach

Ziegler (2000 ) has outlined the basic assumptions concerning human nature that underlie REBT’s personality theory. This appears in Figure 2.1 . I include Ziegler’s views here since he is both an REBT practitioner and a leading personality theorist who co-wrote a stand- ard text on personality theories (Hjelle and Ziegler, 1992 ). It is not known the extent to which his is a consensus view among REBT Downloaded by [New York University] at 06:45 14 August 2016 therapists, but Ziegler’s views, given his status as an internationally respected personality theorist, carry the weight of authority. Hjelle and Ziegler’s (1992 ) nine basic assumptions concerning human nature that underpin all personality theories are:

5 Downloaded by [New York University] at 06:45 14 August 2016

Strong Moderate Slight Mid-range Slight Moderate Strong

Freedom Determinism

Rationality Irrationality

Holism Elementalism

Constitutionalism Environmentalism

Changeability Unchangeability

Subjectivity Objectivity

Proactivity Reactivity

Homeostasis Heterostasis

Knowability Unknowability

FigureFigure 16.1 16.1 REBT’s Position on the Nine Basic Assumptions Concerning Human Nature (The shaded areas indicate the degree to which REBT favours one of the two human bipolar extremes.) Reprinted with permission from Ziegler (2000) REBT’S POSITION ON HUMAN NATURE

Freedom – Determinism How much internal freedom do people have and how much are they determined by external and internal (e.g. biological) factors? Rationality – Irrationality To what extent are people primarily rational, directing themselves through reason, or to what extent are they guided by irrational factors? Holism – Elementalism T o w hat extent are people best comprehended as a whole or to what extent by being broken down into their constituent parts? Constitutionalism – Environmentalism To what extent are people the result of constitutional factors and to what extent are they products of environmental in uences? Changeability – Unchangeability T o w hat extent are people capable of fundamental change over time? Subjectivity – Objectivity T o w hat extent are people in uenced by subjective factors and to what extent by external, objective factors? Proactivity – Reactivity T o w hat extent do people generate their behaviour internally (proactivity) and to what extent do they respond to external stimuli (reactivity)? Homeostasis – Heterostasis T o w hat extent are humans motivated primarily to reduce ten- sions and maintain an inner homeostasis and to what extent are they motivated to actualize themselves? Knowability – Unknowability To what extent is human nature fully knowable? Downloaded by [New York University] at 06:45 14 August 2016 Phenomenological and stoic emphases

REBT agrees, in large part, with phenomenologists whose position is that we respond to events not as they are but more by how we see

7 RATIONAL EMOTIVE BEHAVIOUR THERAPY

them. It also agrees, in large part, with the Stoic philosopher, Epictetus, who said that, “Men are disturbed not by things but by the views they take of them.” These two emphases show how much REBT stresses cognition in human disturbance and health. However, as I make clear in C hapter 4, REBT emphasizes in particular the role of rigid and extreme beliefs in human disturbance, which the phenomenologists and the Stoics do not. Thus, I have updated Epictetus’s dictum to read:

People are disturbed not by things, but by the rigid and extreme beliefs that they hold about things.

Although REBT has changed its name twice since its establishment as rational therapy in 1955 (it became rational-emotive therapy in 1962 and rational emotive behaviour therapy in 1993), it has always maintained the cognitive (rational) dimension in its name.

Affective-experiential emphasis

W hile it agrees with Epictetus in the above respect, REBT does not go along with another Stoic view that we should strive to develop non-emotional responses to life adversities. In this regard, REBT is highly affective in emphasis and encourages people to have passionate positive and negative responses to things that are important to them, as long as these responses are healthy. This includes strong negative responses to signi cant life adversities such as loss. For example, to feel very sad when one loses a loved one is healthy. I will discuss REBT’s distinctive view on the differences between healthy and unhealthy negative emotions later ( C hapter 6) . Rational therapy was renamed rational-emotive therapy because many people, believed, erroneously, that the therapy neglected emotion. This was not the case then and it is not the case now. Downloaded by [New York University] at 06:45 14 August 2016 REBT also has an experiential element in that it advocates that people do fully experience their feelings. However, REBT holds that fully experiencing unhealthy negative feelings is not curative in itself, but is useful in that it helps the person to identify the irrational beliefs that underpin these feelings.

8 REBT’S POSITION ON HUMAN NATURE

Behavioural emphasis

When rational-emotive therapy (RET) became rational emotive behaviour therapy (REBT) in 1993, it was again because Ellis considered that people thought, again erroneously, that RET neglected behaviour. This was again incorrect. REBT argues that people are at their happiest when they are actively pursuing their personally meaningful goals and when they disturb themselves they often act in ways that deepen this disturbance.

Psychological interactionism

So far, I have outlined REBT’s cognitive, emotional and behavioural emphases. It also adheres strongly to the principle of psychological interactionism, which argues that cognition, emotion and behaviour are not separate psychological systems, rather, they are overlapping processes and that when we think in terms of cognition, for example, we should also think of the affective (emotional) and behavioural (actual behaviours or action tendencies) components of these cognitions (Ellis, 1994 ). Indeed, REBT theory has emphasized this principle of psychological interactionism from its very inception (Ellis, 1962 ). Ellis has always urged REBT therapists to target all three systems in the change process and, in particular, has always advocated that without corresponding behavioural change, affective and cognitive change is transitory (Ellis, 1962 ). The misconception that REBT neglects behavioural change prompted Ellis to rebrand rational-emotive therapy (RET) as rational emotive behaviour therapy (REBT) in 1993.

Responsible hedonism Downloaded by [New York University] at 06:45 14 August 2016

Albert Ellis often said that the purpose of life was to live healthily and to have a ball. While many have interpreted this to be a self- ish “me-oriented” philosophy, Ellis did not mean this. The hedonism that REBT is based on may be called responsible h edonism. 9 RATIONAL EMOTIVE BEHAVIOUR THERAPY

It is responsible in three ways. First, it encourages the person to be mindful of his long-term goals as well as his short-term goals. Here, as elsewhere, it advocates a “both-and” rather than an “either-or” position. Thus, REBT encourages the person to ensure that he meets some of his short-term desires as he pursues his longer term goals. It argues that the exclusive pursuit of short-term goals, without being mindful of one’s longer term objectives, eventually leads to disen- chantment, meaningless and ill health, while the exclusive pursuit of long-term goals without being mindful of one’s shorter term goals leads to a life that is devoid of fun and pleasure. The second way in which REBT’s concept of hedonism is responsible is that it encourages the person to be mindful of the fact that as he pursues his short- and long-term goals other people in his social world are pursuing theirs and while his prime responsibility is to himself (after all, if he does not look after himself, who will?) his secondary responsibility is to help others in the pursuit of their goals. Being primarily responsible to himself does not mean that he will always put himself rst. Far from it. For there will be times when he will put the desires and goals of others before his own (e.g. those of young children and aging relatives), but he will not do so in any rigidly self-denying manner. T he nal way in which REBT’s concept of hedonism is responsible is that it encourages the person to be mindful of the environmental context in which he lives. While his environment may sustain him in the present, it may not sustain those who follow him in the future and thus, as he pursues his short- and longer term goals, it would be wise if he does so responsibly with minimal negative impact on the environment and he may well curtail such pleasurable and meaningful activities if they harm the environment. Downloaded by [New York University] at 06:45 14 August 2016 Psychodynamic features

A lthough REBT was created, in part, out of Ellis’s disaffection with psychoanalysis, it is easy to assume that, as a result, REBT has

10 REBT’S POSITION ON HUMAN NATURE

dispensed with all psychodynamic insights. This is not the case. Thus, REBT therapists do agree with our psychodynamic colleagues that humans are in uenced by unconscious ideas. However, we hold that, in the main, these ideas can be relatively easily dis- covered and brought to the client’s conscious mind and are not deeply buried within the client’s psyche requiring a long period of exploration to be made conscious. Also, we agree with our psychodynamic colleagues that humans erect defences to protect themselves from threats to their ego (Freud, 1937 ). Actually, we go beyond this idea and argue that humans also erect defensive manoeuvres to protect themselves from threats to non-ego aspects of their personal domain.

Constructivistic emphasis

Ellis ( 1994 ) has argued that REBT is best seen as one of the constructivistic cognitive therapies. In REBT, the constructivistic focus is seen in the emphasis that REBT places on the active role that humans play in constructing their irrational beliefs and the distorted inferences that they frequently bring to emotional episodes. I will discuss this in more detail in Chapter 14 .

Existential-humanistic emphasis

REBT has an existential-humanistic outlook, which is intrinsic to it and which is omitted by most other approaches to CBT. Thus, it sees people as holistic, goal-directed individuals who have importance in the world just because they are human and alive; it unconditionally accepts them with their limitations; and it particularly “focuses

Downloaded by [New York University] at 06:45 14 August 2016 upon their experiences and values, including their self-actualising potentialities” (Ellis, 1980a : 327). It also shares the views of ethi- cal humanism by encouraging people to emphasize human interest (self and social) over the interests of deities, material objects and lower animals.

11 RATIONAL EMOTIVE BEHAVIOUR THERAPY

General semantics emphasis

General semantics theory (GST) holds that people are in uenced by the language that they employ to others and to themselves and that when we use imprecise language we are in uenced for the worse (Korzybski, 1933 ). Thus, general semantics theory and REBT share a common goal in identifying such imprecise language forms as over-generalizations, always-never thinking and the “is” of predica- tion and of identity and helping people to change them. As noted earlier in this chapter, because of its interactional or multifaceted view of mental events, REBT does not neglect emotion and behaviour. However, as S. Nielsen (2006, personal communica- tion) has observed:

Examination of language offers the advantages of representing rigid irrational beliefs in the symbolic form of language where the belief is more easily examined and manipulated. While “should” is not always an indicator of a rigid belief (e.g. “It should rain by April 30th”), if it is used as a synonym for “must” it is an indicator for a rigid belief. The following words and phrases – “should”, “ought”, “must”, “have to”, “got to”, “need to”, supposed to”, “awful”, “horrible”, “unbearable”, “terrible”, “better person”, “bad person”, “jerk”, and “saint” can all become useful foci for intervention, depending on the client’s particular beliefs.

This means that such language is only indicative of the presence of irrational beliefs and that it is not inevitable that when clients use such seemingly irrational language they are necessarily thinking irrationally. As general semanticists note, the map is not the terri- tory and thus the meaning underpinning words is of more interest to REBT therapists than the words themselves. Having said that, there

Downloaded by [New York University] at 06:45 14 August 2016 may be some therapeutic bene t in encouraging clients to change their language in a comprehensive approach to helping them to think rationally. REBT differs from GST in that it helps people to see that their imprecise language (e.g. “He is a ‘jerk”) frequently stems from

12 REBT’S POSITION ON HUMAN NATURE

their rigid beliefs and that it is easier to think in more precise ways when one has rst changed one’s rigid beliefs to exible beliefs (see Chapter 21 ). In addition, REBT places more emphasis on the role of behaviour in helping people to think more precisely than does GST.

Systemic emphasis

REBT agrees with systems approaches to psychotherapy that people need to be understood within context. Thus, REBT holds that people are both in uenced by and in uence the interpersonal systems in which they live. However, REBT also states that ultimately such systems and the interpersonal interactions that occur within them only contribute to our clients’ disturbances they do not determine them. The basic REBT point is as outlined in Chapter 3 : “People are disturbed not by things, but by the rigid and extreme beliefs that they hold about things.”

REBT is against religiosity not religion

Albert Ellis regarded himself as a probabilistic atheist, but held that religious belief is not an obstacle to the effective practice of REBT. The only time religious belief is an obstacle in REBT is when the REBT therapist brings his or her devout religious beliefs to the therapy. However, what is damaging here is the devoutness of the belief, not the religious content and the intrusion of any devout therapist belief in the therapeutic process is counter-therapeutic even when the content of the devout belief is REBT theory! Thus it is not religion that is the problem here; it is religiosity (Ellis, 1983a ). REBT theory does have echoes in certain religious thought. For

Downloaded by [New York University] at 06:45 14 August 2016 example the principle of other-acceptance in REBT (see Chapters 5 and 9 ) is similar to the Christian doctrine of accepting the sinner, but not the sin, although the idea that a person can be a sinner is problematic in REBT since this involves labelling a person with his behaviour.

13 This page intentionally left blank Downloaded by [New York University] at 06:45 14 August 2016 REBT’S DISTINCTIVE ABC MODEL 3

REBT’s distinctive ABC model

Many approaches to CBT make use of what is known as the ABC model. In its general form “A” stands for an event, “B” stands for the belief about this event and “C” stands for the consequences (most usually emotional) of holding the belief at “B”. However, when we consider speci c REBT,1 we see that a different, more sophisticated ABC model emerges. I have called this model the situational ABC model. In this model, the ABC factors occur within a situational context. Within this context “A” stands for the aspect of the situation to which we respond (at “C”), “C” stands for this response and “B” stands for the beliefs we hold about the “A” that largely accounts for our response at “C”. If we consider this model more closely we nd the following: 1. “A” is usually inferential in nature. An inference is a hunch or interpretation about reality, which goes beyond the data at hand and may be accurate or inaccurate. Aaron T. Beck (e.g. 1976), the founder of cognitive therapy, has written about the most common inferences that are associated with different emotions and REBT therapists (e.g. Dryden, 2009) have drawn on his work in outlining the kinds of inferences at “A” associated with common emotional disorders at “C” (e.g. threat in anxiety, loss in depression, transgression of a valued personal rule in anger). 2. As we will soon see, beliefs at “B” are either irrational (rigid and extreme) or rational ( exible and non-extreme).

Downloaded by [New York University] at 06:45 14 August 2016 3. “C” stands for the consequences of the beliefs held at “B”. There are three such consequences: emotional, behavioural (overt actions or action tendencies) and thinking.

It is worth knowing in this context that when we consider some of the complexity of REBT’s ABC framework, we discover that cognitions

15 RATIONAL EMOTIVE BEHAVIOUR THERAPY

appear throughout the model. Thus, inferential cognitions occur at “A” and at “C” and beliefs occur at “B”. This is exempli ed below:

A = “I am beginning to lose control of my breathing” (inference at “A”)

B = “I must gain control of my breathing right now and it would be awful if I don’t” (irrational belief at “B”)

C = “If I don’t I will have a heart attack and die!” (inference at “C”)

Having outlined REBT’s distinctive ABC model, I will now discuss in the following two chapters what is perhaps REBT’s most distinctive contribution: its position on irrational and rational beliefs at “B”.

Note

1 E llis ( 1980a ) distinguished between speci c REBT and general REBT. The approach to REBT outlined in this book can be taken to be speci c REBT. Ellis regarded general REBT as synonymous with general REBT. Downloaded by [New York University] at 06:45 14 August 2016

16 IRRATIONAL BELIEFS AT CORE OF PSYCHOLOGICAL DISTURBANCE 4

Irrational beliefs are at the core of psychological disturbance

A ll approaches to psychological treatment are based on how psychological disturbance is conceptualized. A major distinctive theoretical feature of REBT is that people are disturbed not by things but by the irrational beliefs that they take of them. This updated version of Epictetus’s famous dictum (“Men are disturbed not by things but by the views that they take of them”) speci es the type of cognitions that REBT considers to lie at the core of disturbance, namely irrational beliefs. REBT speci es four irrational beliefs: a rigid belief and three extreme beliefs that stem from this rigid belief.

Rigid beliefs

Rigid beliefs (also referred to as religiosity, dogmatism, absolutism and demandingness in the REBT literature) takes the form of musts, demands, absolute shoulds, needs, have tos, got tos, among others. These musts have three foci: self, others and life, as in: • I must … • You (others) must … • Life must … Rigid beliefs, for the most part, tend to be based on our desires. Indeed, REBT stresses that it is a basic design feature of human Downloaded by [New York University] at 06:45 14 August 2016 beings that we have desires. We are either oriented towards something or away from it. Thus, we don’t operate purely on the inferences that we make about the world; rather we hold beliefs (i.e. hold a positive stance or negative stance) concerning what we infer. According to the theory of REBT it is these beliefs that have 17 RATIONAL EMOTIVE BEHAVIOUR THERAPY

a greater impact on how we feel and act than the inferences that we make. Our preferences vary in strength from mild to very strong. REBT theory holds that the stronger our preferences, the more likely we are to transform these preferences into rigidities. Thus, if I mildly want to beat you at tennis, I am unlikely to transform this into a rigid belief. However, if my desire to beat you at tennis is very strong then I am more likely to (but, of course, not guaranteed to) transform this strong desire into a rigid belief (“I really want to beat you at tennis therefore I have to do so”). In this respect, REBT theory makes clear that rigidity is a quality separate from strength of desire. Multiplica- tion of “really” in the above sentence will not become a demand: Thus, “I really, really, really, really, very, very much want to beat you at tennis” will never on its own become a demand, “I must beat you at tennis.” It takes the person to arbitrarily change their non- dogmatic desire to a rigid demand to achieve this transformation. The holding of rigid beliefs represents our attempt to make certain events magically happen. If, indeed, our rigid beliefs had these effects, then it might be sensible for us to hold them. So, if by holding the rigid belief: “I must pass my driving test”, I was guaranteed to pass it, then it would be sensible for me to hold this belief. Sadly, of course, the very holding of a rigid belief does not in uence reality. It only in uences our responses to reality. Conversely, the holding of rigid beliefs is our attempt to exclude the possibility of certain events from happening, even though we are not convinced that they can be so excluded. Thus, when I believe: “I must pass my driving test”, I am attempting to exclude the possibility of failure. As such rigid beliefs are inconsistent with reality in that there is almost always the possibility that such events will occur and, at some level, I know this, I feel disturbed about the prospect of failure. If by believing that I must pass my driving test, I was con-

Downloaded by [New York University] at 06:45 14 August 2016 vinced that I had excluded the possibility of failing it then I would not be disturbed about failure because I would be sure that it could not happen. The fact that I am anxious about failure when I hold a rigid belief about it means that I am not convinced that my rigid belief will do what it is designed to do.

18 IRRATIONAL BELIEFS AT CORE OF PSYCHOLOGICAL DISTURBANCE

Extreme beliefs

According to REBT theory, three extreme beliefs are deemed to stem derived from rigid beliefs. These are known as awfulizing beliefs, discomfort intolerance beliefs and depreciation beliefs. I will consider these one by one.

Awfulizing beliefs Awfulizing beliefs are extreme ideas that we hold about how bad it is when our rigid demands are not met. Thus, as stated above, awfulizing beliefs are derivatives from our rigid beliefs when these aren’t met. In the following examples, the demands are listed in parentheses:

• “(I must be approved) … It is terrible if I am not approved.” • “(You must treat me fairly) … It is awful when you treat me unfairly.” • “(Life must be comfortable) … It is the end of the world when life is uncomfortable.”

Awfulizing beliefs stem from the demand that things must not be as bad as they are and are extreme in the sense that we believe at the time something very much like following: a. nothing could be worse b. the event in question is worse than 100% bad c. no good could possibly come from this bad event.

Discomfort intolerance beliefs D iscomfort intolerance beliefs are extreme ideas that we hold about the tolerability of events when our demands are not met. Thus these beliefs are derivatives from our rigid beliefs when these aren’t met. Downloaded by [New York University] at 06:45 14 August 2016 In the following examples, the demands are listed in parentheses: • “(I must be approved) … I can’t bear it if I am not approved.” • “(You must treat me fairly) … It is intolerable when you don’t treat me fairly.”

19 RATIONAL EMOTIVE BEHAVIOUR THERAPY

• “(Life must be comfortable) … I can’t stand it when it is uncomfortable.”

D iscomfort intolerance beliefs stem from the demand that things must not be as frustrating or uncomfortable as they are and are extreme in the sense that we believe at the time something very much like following: a. If the frustration or discomfort continues to exist it is too hard for me to do anything about it. b. I will die or disintegrate if the frustration or discomfort continues to exist. c. I will lose the capacity to experience happiness if the frustration or discomfort continues to exist.

Depreciation beliefs Depreciation beliefs are extreme ideas that we hold about self, other(s) and/or life when our rigid beliefs are not met. As such, and as stated above, depreciation beliefs are derivatives from our unmet rigid demands. In the following examples, the demands are listed in parentheses: • “(I must be approved) … I am worthless if I am not approved.” • “(You must treat me fairly) … You are a bad person if you don’t treat me fairly.” • “(Life must be comfortable) … Life is bad if it is uncomfortable.” Depreciation beliefs stem from the demand that we, others or life must be as we want them to be and are extreme in the sense that we believe at the time something very much like following: a. A person (self or other) can legitimately be given a single global Downloaded by [New York University] at 06:45 14 August 2016 rating that de nes their essence and the worth of a person is dependent on conditions that change (e.g. our worth goes up when we do well and goes down when we don’t do well). b. Life can legitimately be given a single rating that de nes its essential nature and that the value of life varies according to

20 IRRATIONAL BELIEFS AT CORE OF PSYCHOLOGICAL DISTURBANCE

what happens within it (e.g. the value of life goes up when something fair occurs and goes down when something unfair happens). c . A person can be rated on the basis of one of his or her aspects and life can be rated on the basis of one of its aspects. Downloaded by [New York University] at 06:45 14 August 2016

21 This page intentionally left blank Downloaded by [New York University] at 06:45 14 August 2016 RATIONAL BELIEFS AT CORE OF PSYCHOLOGICAL HEALTH 5

Rational beliefs are at the core of psychological health

A ll approaches to psychological treatment also specify, either explicitly or implicitly, the factors that explain psychological health. If irrational beliefs are deemed to be at the core of psychological disturbance in REBT, it follows that rational beliefs are deemed to be at the core of psychological health. The appropriate dictum might be: “People react healthily to events when they hold exible views of (or more accurately, beliefs about) these events.” This dictum speci es the type of cognitions that are at the core of psychological health, namely rational beliefs. REBT speci es four rational beliefs: a exible belief and three non-extreme beliefs that stem from this exible belief.

Flexible beliefs

Flexible beliefs build on the basic human fact that we form preferences about things and takes the form of non-dogmatic preferences, desires, wishes, wants, among others. Flexible beliefs have two components. In the rst component (which I call the “asserted preference” component), we assert our preferences about what we want to happen or not happen. In the second component (which I call the “negated demand” component), we acknowledge that we do not have to get what we want. As with rigid beliefs, these exible beliefs

Downloaded by [New York University] at 06:45 14 August 2016 have three foci: self, others and life, as in: • “I want X to happen (or not happen) … but, I don’t have to get my desire met …” • “I would prefer it if you (others) … but you (they) don’t have to do what I prefer …” 23 RATIONAL EMOTIVE BEHAVIOUR THERAPY

• “It would be desirable if life … but it doesn’t have to be that way …”

When we hold a exible belief, we are making clear to ourselves and, if appropriate, to others what we desire. However, when we hold a exible belief (rather than a rigid belief), we are not attempting to make certain events magically happen. Rather, we are being realistic since both components that comprise a exible belief are consistent with reality. We can generally prove that we hold a desire and can also prove that we don’t have to get our desire met. Thus when I hold the exible belief: “I want to pass my driving test, but I don’t have to do so”, I can prove that I want to pass my driving test, by giving reasons why it would be good for me to do so (e.g. “I would be less reliant on public transport”, “I could go for long drives over the weekend”, etc.) but I am also acknowledging that this belief does not guarantee that I must pass it. Also, unlike with rigid beliefs, when we hold exible beliefs, we do not attempt to exclude the possibility of certain events from happening. Indeed, we overtly acknowledge this possibility. Thus, when I believe: “I want to pass my driving test, but I don’t have to do so”, I am not attempting to exclude the possibility of failure. Rather, I am acknowledging the possibility that I may fail. As such, exible beliefs are consistent with reality in that there is almost always the possibility that undesirable events will happen.

Non-extreme beliefs

According to REBT theory, three non-extreme beliefs are deemed to stem derived from rigid beliefs. These are known as non-awfulizing beliefs, discomfort tolerance beliefs and acceptance beliefs. I will consider these one by one. Downloaded by [New York University] at 06:45 14 August 2016

Non-awfulizing beliefs Non-awfulizing beliefs are non-extreme ideas we hold about how bad it is when our non-dogmatic preferences are not met.

24 RATIONAL BELIEFS AT CORE OF PSYCHOLOGICAL HEALTH

Thus, non-awfulizing beliefs are derivatives from our exible beliefs when these non-dogmatic preferences aren’t met. In the following examples, the non-dogmatic preferences are in parentheses: • “(I want to be approved, but I don’t have to be) … It’s bad if I am not approved, but not terrible.” • “(I want you to treat me fairly, but regrettably you don’t have to do so) … When you don’t treat me fairly it’s really bad, but not awful.” • “(I very much want life to be comfortable, but unfortunately it doesn’t have to be that way) … If life is uncomfortable, that’s very bad, but not the end of the world.” If you look carefully at the non-awfulizing beliefs above (i.e. the ones that are not in parentheses) you will see that they are made up of two components.

“Asserted badness” component The rst component puts forward the idea that it is bad when we don’t get what we want and this is what I call the “asserted badness” component: • “It’s bad if I am not approved …” • “When you don’t treat me fairly, it’s really bad …” • “If life is uncomfortable, that’s very bad …”

“Negated awfulizing” component The second component acknowledges that while it is bad when we don’t get what we want, it is not terrible, awful or the end of the world. This is what I call the “negated awfulizing” component.

Downloaded by [New York University] at 06:45 14 August 2016 These are shown in italics in the following: • “ It ’s bad if I am not approved, but not terrible .” • “When you don’t treat me fairly it’s really bad, but not awfull.” • “If life is uncomfortable, that’s very bad, but not the end of the worldd .”

25 RATIONAL EMOTIVE BEHAVIOUR THERAPY

Non-awfu lizing beliefs stem from the non-dogmatic preference that we would like things not to be as bad as they are, but that doesn’t mean that they must not be as bad. These beliefs are non-extreme in the sense that we believe at the time something very much like the following: a. Things could always be worse. b. The event in question is less than 100% bad. c. Good could come from this bad event.

Discomfort tolerance beliefs Discomfort tolerance beliefs are non-extreme ideas that you hold about the tolerability of events when your non-dogmatic preferences are not met. Thus, discomfort tolerance beliefs are derivatives from your exible beliefs when these non-dogmatic preferences are not met. In the following examples, the non-dogmatic preferences are in parentheses: • “(I want to be approved, but I don’t have to be) … When I am not approved it is diff cult to bear, but I can bear it and it’s worth bearing because I don’t want to live my life worried about disapproval.” • “(I want you to treat me fairly, but regrettably you don’t have to do so) … When you don’t treat me fairly it’s really hard to tolerate, but I can tolerate it and it’s worth it to me to do so because I don’t want to be overly affected about what you do.” • “(I very much want life to be comfortable, but unfortunately it doesn’t have to be the way I want it to be) … If life is uncomfortable, that’s hard to stand, but I can stand it and it is in my best interests to do so because I want to get on with life.” If you look carefully at discomfort tolerance beliefs (i.e. the ones that are not in parentheses), you will see that they are made up of three components. Downloaded by [New York University] at 06:45 14 August 2016 “Asserted struggle” component The rst component puts forward the idea that it is diff cult tolerating not getting what we want and is what I call the “asserted struggle” component:

26 RATIONAL BELIEFS AT CORE OF PSYCHOLOGICAL HEALTH

• “When I am not approved, it is diff cult to bear …” • “When you don’t treat me fairly, it’s really hard to tolerate …” • “If life is uncomfortable, that’s hard to stand …”

“Negated unbearability” component The second component acknowledges that while it is a struggle to put up with what we don’t want, it is possible for us to do so and that it isn’t unbearable. This is what I call the “negated unbearability” component. This component is shown in italics in the examples below: • “When I am not approved it is diff cult to bear, but I can bear itt …” • “When you don’t treat me fairly it’s really hard to tolerate, but I can tolerate itt …” • “If life is uncomfortable, that’s hard to stand, but I can stand itt …”

“Worth bearing” component The third component addresses the point that it is often worth it to you to tolerate the situation in which you don’t get what you want. This is what I call the “worth bearing” component. This component is shown in italics in the examples below. Note that, in each case, the reason why it is worth tolerating is speci ed: • “When I am not approved it is diff cult to bear, but I can bear it and it’s worth bearing because I don’t want to live my life worried about disapprovall.” • “When you don’t treat me fairly it’s really hard to tolerate, but Downloaded by [New York University] at 06:45 14 August 2016 I can tolerate it and it’s worth it to me to do so because I don’t want to be overly affected about what you do .” • “If life is uncomfortable, that’s hard to stand, but I can stand it and it is in my best interests to do so because I want to get on with life .”

27 RATIONAL EMOTIVE BEHAVIOUR THERAPY

D iscomfort tolerance beliefs stem from the non-dogmatic preference that it is undesirable when things are as frustrating or uncomfortable as they are, but unfortunately things don’t have to be different. It is non-extreme in the sense that we believe at the time something very much like the following:

a. It is hard, but not too hard if the frustration or discomfort continues to exist. b. I will struggle if the frustration or discomfort continues to exist, but I will neither die nor disintegrate. c. I will not lose the capacity to experience happiness if the frustration or discomfort continues to exist, although this capacity will be temporarily diminished. d. The frustration or discomfort is worth tolerating.

Acceptance beliefs Acceptance beliefs are non-extreme ideas that we hold about self, other(s) and/or the world when we don’t get what we want, but do not demand that we have to get what we want. As such, acceptance beliefs are derivatives from our exible beliefs when these non- dogmatic preferences aren’t met. In the following examples, the non-dogmatic preferences are in parentheses: • “(I want to be approved, but I don’t have to be) … When I am not approved that is bad, but I am not worthless. I am a fallible human being who is not being approved on this occasion.” • “(I want you to treat me fairly, but regrettably you don’t have to do so) … When you don’t treat me fairly that is very unfortunate, but you are not a bad person. Rather, you are a fallible human being who is treating me unfairly.” • “(I very much want life to be comfortable, but unfortunately it Downloaded by [New York University] at 06:45 14 August 2016 doesn’t have to be the way I want it to be) … If life is uncomfortable it is only uncomfortable in this respect which is unfortunate. However, it doesn’t prove that the world is a rotten place. The world is a complex place where many good, bad and neutral things happen.”

28 RATIONAL BELIEFS AT CORE OF PSYCHOLOGICAL HEALTH

If you look carefully at the acceptance beliefs (i.e. the ones that are not in parentheses) you will see that they are made up of at least three components.

“Evaluation of a part of self, other or what has happened to self” component The rst component acknowledges that it is possible and realistic to evaluate a part of oneself, another person or what has happened to oneself as shown in italics below:

• “When I am not approved that is badd …” • “When you don’t treat me fairly that is very regrettable …” • “If life is uncomfortable it is only uncomfortable in this respect which is unfortunate … ”

“Negation of depreciation” component The second component puts forward the idea that it is not possible to evaluate globally a person or life conditions when we don’t get what we want. I call this the “negation of depreciation” component. These are shown in italics below: • “When I am not approved that is bad, but I am not worth less …” • “When you don’t treat me fairly that is very regrettable, b ut you are not a bad person ….” • “If life is uncomfortable it is only uncomfortable in this respect which is unfortunate. However, it doesn’t prove that the world is a rotten place …”

“Assertion of acceptance” component

Downloaded by [New York University] at 06:45 14 August 2016 The third component asserts the idea that when we don’t get what we want, this does not affect the fallibility of people and the complexity of life. This is what I call the “assertion of acceptance” component.

29 RATIONAL EMOTIVE BEHAVIOUR THERAPY

T hese are shown in italics below: • “When I am not approved that is bad, but I am not worthless. I am a fallible human being who is not being approved on this occasion .” • “When you don’t treat me fairly that is very regrettable, but you are not a bad person. Rather you are a fallible human being who is treating me unfairly .” • “If life is uncomfortable it is only uncomfortable in this respect which is unfortunate. However, it doesn’t prove that the world is a rotten place. The world is a complex place where many good, bad and neutral things happen .” Acceptance beliefs are non-extreme in the sense that we believe at the time something very much like the following:

a. A person (self or other) cannot legitimately be given a single global rating that de nes their essence and their worth, as far as they have it and is not dependent on conditions that change (e.g. my worth stays the same whether or not I do well). b. T he world cannot legitimately be given a single rating that de- nes its essential nature and that the value of the world does not vary according to what happens within it (e.g. the value of the world stays the same whether fairness exists at any given time or not). c. It makes sense to rate discrete aspects of a person and of the world, but it does not make sense to rate a person or the world on the basis of these discrete aspects. Downloaded by [New York University] at 06:45 14 August 2016

30 DISTINCTIONS BETWEEN UNES AND HNES 6

Distinction between unhealthy negative emotions (UNEs) and healthy negative emotions (HNEs)

REBT is unique among the cognitive-behavioural therapies in distinguishing between emotions that are negative in tone, but largely healthy in effect and emotions that are negative in tone and largely unhealthy in effect. The former are known as healthy negative emotions (HNEs) while the latter are known as unhealthy negative emotions (UNEs). Unfortunately, we do not have good words in the English language for UNEs and HNEs and thus, different REBT theorists have used different lexicons in this respect. My own (e.g. Dryden, 2002) is as shown in Table 6.1 . REBT’s distinction between UNEs and HNEs follows logically from REBT’s position on the difference between irrational (i.e. rigid and extreme) beliefs and rational (i.e. exible and non-extreme) beliefs. On the latter difference, REBT theory holds that rational and irrational beliefs are qualitatively different. This means that while a person holds a rational belief about an adversity, it is not possible for that person to hold an irrational belief about that adversity and vice versa. Now, according to REBT theory, it is possible for a person to hold a rational belief about a negative activating event and the very next minute hold an irrational belief about that same event, but the contemporaneous holding of a rational belief with its irrational belief counterpart is not possible. Now, in REBT, UNEs are deemed to stem from irrational beliefs Downloaded by [New York University] at 06:45 14 August 2016 about adversities while HNEs are deemed to stem from rational beliefs about these adversities. Since rational beliefs and irrational beliefs are held to be qualitatively different, it follows that UNEs

31 RATIONAL EMOTIVE BEHAVIOUR THERAPY

Table 6.1 Unhealthy negative emotions (UNEs) and healthy negative emotions (HNEs) in REBT theory

UNEs HNEs Anxiety Concern Depression Sadness Guilt Remorse Shame Disappointment Hurt Sorrow Unhealthy anger Healthy anger Unhealthy jealousy Healthy jealousy Unhealthy envy Healthy envy Source: Dryden (2002)

are qualitatively different from HNEs. For example, using the list in Table 6.1 , it is not possible for a person to feel anxious and concerned at the same time. This is why in REBT our goal is to help a person who feels anxious about an adversity to feel concerned, but not anxious about that adversity. Other approaches to CBT would consider it to be appropriate and legitimate to help a person to feel less anxious about an adversity. REBT therapists would be reluctant to do this because the achievement of this goal would involve helping the person to hold their irrational belief, albeit with less intensity rather than to think rationally. As I mentioned earlier, we have no universally accepted lexicon that keenly discriminates UNEs from HNEs. Given this, REBT therapists do not rely on these words alone to help their clients to discriminate UNEs from HNEs. We also make use of the behavioural and thinking consequences of rational and irrational beliefs as well as the beliefs themselves. For example, let’s suppose that a client Downloaded by [New York University] at 06:45 14 August 2016 is not sure whether he (in this case) was experiencing anxiety or concern in a given situation. You may help him to identify his emotion at “C” by identifying his belief (irrational in anxiety, rational in concern), the behaviour accompanying his emotion (avoiding the threat, for example, in anxiety, confronting the threat in concern)

32 DISTINCTIONS BETWEEN UNES AND HNES

and/or his subsequent thinking (overestimating the negativity of the consequences if the threat were to materialize in anxiety; making a realistic estimation of these consequences in concern). W hile less frequently mentioned in the literature, REBT theory also distinguishes between unhealthy positive emotions (UPEs) and healthy positive emotions (HPEs). Unhealthy positive emotions (such as mania) tend to stem from rigid beliefs that are met and from the extreme beliefs that accompany these met rigid beliefs. For example, if I believe that I must get promotion and I do in fact get it, then I may well conclude that it is wonderful that I did so and feel manic as a result. Although these manic feelings are positive in tone, they are largely unhealthy in effect in that they tend to lead people to act in disinhibited ways. B y contrast, healthy positive emotions (such as delight) tend to stem from exible beliefs that are met and from the non-extreme beliefs that accompany these met non-dogmatic beliefs. For example if I believe that I want, but don’t have to get, promotion and I do in fact get it, then I may well conclude that it is great (but not wonderful) that I did so and feel delight as a result. These feelings of delight are positive in tone and they are largely healthy in effect in that they tend to lead people to celebrate appropriately, rather than act in disinhibited ways. Downloaded by [New York University] at 06:45 14 August 2016

33 This page intentionally left blank Downloaded by [New York University] at 06:45 14 August 2016 REBT’S KEY PRINCIPLE OF EMOTIONAL RESPONSIBILITY 7

REBT’s key principle of emotional responsibility

One of REBT’s most fundamental principles is that of emotional responsibility. This principle is at the heart of the ABC model of psychological disturbance which, as we have seen, states that it is our beliefs about the events in our lives that are centrally implicated in our emotional and behavioural responses to these events. This does not mean that these events do not contribute to our problems, but that they do not create or lie at the centre of our emotional experiences. T he principle that it is clients’ beliefs that lie at the core of their experiences and that they are responsible for these beliefs is a simple one which clients may have enormous diff culty in grasping fully because while they may intellectually understand it, being able to integrate it into their lives in a way that makes a fundamental difference to their lives is an entirely different matter. Thus, REBT therapists tend to keep returning to this principle and keep emphasizing it, particularly when their clients indicate that events directly cause their emotional and behavioural responses. REBT therapists do not bring this principle to their clients’ atten- tion every time they say something like “he makes me upset” or “she made me disturbed”, etc. – far from it. Doing so will only serve as an irritant to clients. However, REBT therapists can usefully refer to the “emotional responsibility” principle at important junctures in the therapeutic process since this will serve as a helpful reminder for clients to look at B–C connections rather than A–C connections. Downloaded by [New York University] at 06:45 14 August 2016 Practically, there are a number of ways in which REBT therapists encourage clients to become more aware of the emotional responsibility principle. One is to suggest that they watch television and note the extent to which people use A–C language. They can then

35 RATIONAL EMOTIVE BEHAVIOUR THERAPY

apply this exercise in real life. It may also be helpful for them to rephrase people’s language (in their own mind, not directly to these people!) so that they can get used to changing A–C language to B–C language. If, for example, a client hears somebody say “He made me upset”, she can change this in her own mind to “She made herself upset about what he said and this is how she did it.” Encouraging clients to look for the rigid beliefs (e.g. musts), awfulizing beliefs, discomfort intolerance beliefs and depreciation beliefs in their and other people’s thinking serves to reinforce the emotional responsibility principle. They can then be helped to see the connection between such beliefs and the ensuing emotional and behavioural responses.

Emotional responsibility can be accepted without blame

A common objection to the concept of emotional responsibility is that it implies blame. This is not the case and this is how I explain it to those who make the objection:

You have made a major criticism of the principle of emotional responsibility which is so central to REBT theory. When someone is raped, it is possible to argue that this very negative A “causes” the intense healthy distress that the person almost invariably experiences. However, if she experiences emotional disturbance, particularly well after the event happened, REBT theory holds that she is responsible for her disturbed feelings through the irrational beliefs that she brings to the event. But, and this is important, there is a world of difference between being responsible for one’s disturbance and being blamed for having these feelings. The concept of responsibility in this sit-

Downloaded by [New York University] at 06:45 14 August 2016 uation means that the person largely disturbs herself about the event because of the irrational beliefs she brings to that event. The concept of blame here means that someone believes that the person absolutely should not experience such disturbed feelings and is a bad person for having these feelings.

36 REBT’S KEY PRINCIPLE OF EMOTIONAL RESPONSIBILITY

This is obviously nonsense for two reasons. First, if the person disturbs herself about being raped then all the conditions are in place for her to do so. In other words, if she holds a set of irrational beliefs about the event, then empirically she should disturb herself about it. It is obviously inconsistent with reality for someone to demand that the person absolutely should not disturb herself in this way. Second, even if we say that it is bad for that the person disturbed herself, there is no reason to conclude that she is a bad person for doing so. There is, of course, evidence that she is a fallible human being who understandably holds a set of irrational beliefs about a tragic event. Rather than being blamed for her disturbance, she should preferably be helped to overcome it. The concept of blame in this situation also tends to mean, at least in some people’s eyes, that she is responsible for being raped and therefore should be blamed for it happening. This is again nonsense. L et me be quite clear about this. Rape inevitably involves coer- cion. Even if the woman is responsible for “leading the man on”, he is responsible for raping her. Nothing, including whether the woman experiences distressing or disturbed feelings, absolves him from this responsibility. So, if a woman has been raped nothing that she did or failed to do detracts from the fact that the rapist is solely responsible for committing the rape. As such, the woman cannot be held responsible for being raped. She can be held responsible for “leading the man on” if this can be shown to be the case. But, I repeat, she cannot be held responsible for being raped. Thus, the principle of emotional responsibility means in this situation that the woman is responsible for her disturbed feelings only. She is not to be blamed for this, neither is she to be held responsible for being raped no matter how she has behaved in the situation.

Downloaded by [New York University] at 06:45 14 August 2016 Emotional responsibility can be taken without others discharging responsibility for their behaviour

Another common misconception about the concept of emotional responsibility concerns what Howard Young (in Dryden 1989) has

37 RATIONAL EMOTIVE BEHAVIOUR THERAPY

called the cop-out criticism. Here the objection is made that if a person accepts responsibility for disturbing himself about another’s bad behaviour then that person will say that their behaviour has got nothing to do with the rst person’s disturbed response. This is again not the case and this is how I explain it to those who make the objection:

The cop-out criticism of emotional responsibility can be stated thus. If a person is largely responsible for her own disturbed feelings, then if you act nastily towards her all you have to say is that because she largely disturbs herself about your bad behaviour then her feelings have nothing to do with you. A rapist is responsible for carrying out a rape regardless of how the person who has been raped feels and regardless of any so-called mitigating circumstances. Now if I act nastily towards you I am responsible for my behaviour regardless of how you feel about my behaviour. If my behaviour is nasty then I cannot be absolved of responsibility for my action just because you are largely responsible for your making yourself disturbed about the way I have treated you. Don’t forget, if my behaviour is that bad, it is healthy for you to hold strongly a set of rational beliefs about it and, whereas I cannot be held responsible for your disturbance, I can be said to be responsible for your distress. Thus, I cannot cop out of my responsibility for my own behaviour or for “distressing” you. Downloaded by [New York University] at 06:45 14 August 2016

38 EXPLAINING WHY CLIENTS’ INFERENCES ARE DISTORTED 8

Explaining why clients’ inferences are highly distorted

One of the diffculties novice therapists have in practising REBT is in making sense of their clients’ distorted inferences. They know that they are supposed to encourage their clients to assume temporarily that their inferences are true, but sometimes when they do this and these inferences are highly distorted, they run into great diff culty clinically. For example, let’s suppose that a client reports that she (in this case) was panicking the night before. Not unreasonably, the novice REBT therapist asks the client what she was panicking about to which the client responds that she was most scared of dying from a heart attack. This, of course, is an inference, so the novice REBT knows not to challenge it, but to encourage the client to assume temporarily that she will die from a heart attack as a way of identifying and disputing her irrational beliefs about what the therapist thinks is an “A”. And, indeed, from one perspective it is an “A”, but it is also a thinking consequence (at “C”) of a prior irrational belief about a less distorted “A” and it is this standpoint that is more likely to yield the best results clinically in this given situation. This example shows that highly distorted inferences are often best conceptualized in REBT as cognitive consequences (i.e. “C”) of rigid and extreme irrational beliefs about less distorted inferences at “A”. While schema-focused therapy (e.g. Young and Klosko, 1993) also makes this point, only REBT does this in the context of the “ABC” framework for which it is known. Downloaded by [New York University] at 06:45 14 August 2016

39 This page intentionally left blank Downloaded by [New York University] at 06:45 14 August 2016 POSITION ON HUMAN WORTH 9

Position on human worth

REBT has a distinctive position on the issue of human worth. To be accurate, it has two positions, one that it particularly espouses and another that is less favoured, but acceptable. Its preferred position is that it makes little sense to say that as humans we have or lack worth. We exist in a social world and we have a choice to exist healthily or miserably, with or without due regard to our social groups and to our environment. We are happiest when we are actively pursuing goals that are meaningful. We do not need to consider ourselves worthwhile in order to be happy and since one of the sources of emotional disturbance is rooted in our tendency to view ourselves and others as conditionally worthwhile, conditional human worth interferes with our emotional wellbeing and happiness. REBT considers that it is just as feasible to say that humans are worthless as it is to say that we are worthwhile. Assigning worth to humans is, therefore, a choice and if we decide to choose this position we are advised to choose a philosophy of unconditional worth rather than a philosophy of conditional worth as discussed below.

Conditional human worth

T he philosophy of conditional human worth comprises a number of positions:

Downloaded by [New York University] at 06:45 14 August 2016 1. It implies that humans are simple organisms that merit a global evaluation. 2. It implies that a person’s worth can go up and down based on the presence or absence of certain conditions deemed important to the person.

41 RATIONAL EMOTIVE BEHAVIOUR THERAPY

3. It makes the error of over-generalization when it bases a person’s worth on a single or small number of traits, charac- teristics and/or behaviours (e.g. “My acting poorly means that I am bad”). 4. It implies that humans are perfectible. 5. It encourages emotional disturbance, which occurs when conditional, global evaluations of worth are assigned to humans.

Unconditional acceptance of humans

The preferred alternative to the philosophy of conditional human worth in REBT is the philosophy known as unconditional acceptance of humans. This philosophy comprises a number of positions: 1. It acknowledges that humans are a complex mixture of the good, the bad and the neutral and thus too complex to merit a global evaluation. 2. It states that a person can accept self or others unconditionally, i.e. whether or not certain desired conditions are present. 3. It avoids making the error of over-generalization since the concept of complexity can incorporate positive, negative and neutral features (e.g. “My acting poorly does not mean that I am bad. I am complex as a human and can act poorly, well and neutrally”). 4. It acknowledges the fallibility and non-perfectibility of humans. 5. It protects people from emotional disturbance. Much (but far from all) emotional disturbance stems from assigning conditional, global evaluations of worth to humans. In unconditional acceptance of humans, such assignations are not made. Downloaded by [New York University] at 06:45 14 August 2016 Unconditional human worth

REBT theory advocates unconditional acceptance as the preferred healthy alternative to conditional human worth because it does not use the concept of worth with its attendant problems (mainly

42 POSITION ON HUMAN WORTH

that it implies that humans can be globally rated as having worth). However, it has a fall-back less preferred alternative known as “unconditional human worth”. This philosophy comprises a number of positions:

1. Humans can be given global evaluations with respect to worth. 2. It is best to give humans positive global evaluations with respect to worth. 3. These positive global evaluations remain in place no matter what and are therefore unconditional (e.g. “Even though I have acted poorly, I am worthwhile”). 4. Humans are worthwhile as long as they are alive, fallible and human. This position is vulnerable in the sense that it could just as easily be argued that humans are worthless for the same reasons. However, this position has pragmatic value and is especially useful with clients who do not understand or want to use the concept of unconditional acceptance of humans. Downloaded by [New York University] at 06:45 14 August 2016

43 This page intentionally left blank Downloaded by [New York University] at 06:45 14 August 2016 DISTINCTION BETWEEN EGO DISTURBANCE AND HEALTH 10

Distinction between ego and discomfort disturbance and health

D ifferent REBT theorists have proposed somewhat different approaches to distinguishing between different fundamental types of disturbance and health. In this chapter, I will review three such approaches that show REBT’s distinctiveness.

Approach 1: Ego and discomfort disturbance and health

REBT is unique in the distinction that it makes between two fundamental forms of disturbance and health. I will consider the two fundamental disturbances rst. These are ego disturbance and discomfort disturbance – or what I have called non-ego disturbance (Dryden, 1999 ). E llis rst made this distinction in 1979–80, when he published an important two-part article on discomfort anxiety and contrasted this with ego anxiety (Ellis, 1979 , 1980b ).

Ego disturbance and discomfort disturbance Ego disturbance This disturbance takes the form of self-depreciation (see also Downloaded by [New York University] at 06:45 14 August 2016 Chapter 9 ). This occurs when I make demands on myself and I fail to meet these demands. It involves: (a) the process of giving my “self” a global negative rating; and (b) “devil-ifying” myself as being bad or less worthy. This second process rests on a theological concept and implies either that I am undeserving of pleasure on earth or that

45 RATIONAL EMOTIVE BEHAVIOUR THERAPY

I should rot in hell as a subhuman (devil). Ego disturbance is also found in demands on others (e.g. “You must treat me well or I am no good”) and in demands on life conditions (e.g. “I must be promoted and if I am not I am useless”).

Discomfort disturbance This form of disturbance stems from the irrational belief, “I must feel comfortable and have comfortable life conditions”. Conclusions that stem from this premise are (a) “It’s awful when these life conditions do not exist” and (b) “I can’t stand the discomfort when these life conditions do not exist”. Discomfort disturbance occurs in different forms and is central to a full understanding of a number of emotional and behavioural disturbances such as unhealthy anger, agoraphobia, depression, procrastination and alcoholism. Discomfort disturbance usually gets in the way of people working persistently hard to effect productive psychological change and is thus a major form of “resistance” to change in psychotherapy. It is useful to note that, according to REBT theory, rigid beliefs held about other people involve either ego disturbance (for example “You must approve of me and if you don’t it proves that I am less worthy”) or discomfort disturbance (“You must approve of me and give me what I must have and if you don’t I can’t bear it and you are no good for giving me such discomfort”), and thus do not represent a (third) fundamental human disturbance, since they include one or other of the two fundamental disturbances.

Ego health and discomfort tolerance According to REBT theory there are two types of psychological health: ego health and discomfort tolerance. Downloaded by [New York University] at 06:45 14 August 2016 Ego health The most common form of ego health is unconditional self- acceptance (as discussed in Chapter 9). This occurs when I hold preferences about myself, but do not demand that I must achieve

46 DISTINCTION BETWEEN EGO DISTURBANCE AND HEALTH

these preferences. When we accept ourselves, we acknowledge that we are fallible human beings who are constantly in ux and too complex to be given a single legitimate rating. REBT theory advocates that it is legitimate, and often helpful, to rate one’s traits, behaviours, etc., but that it is not legitimate to rate one’s self at all, even in a global positive manner, since positive self-rating tends to be conditional on doing good things, being loved and approved, and so on. E go health is also found in exible beliefs about others (e.g. “I want you to treat me well, but you do not have to do so. If you don’t, I am the same fallible human being as I would be if you did treat me well”) and in exible beliefs about life conditions (e.g. “I want to be promoted, but it isn’t essential that I am. If I am not, I am not useless. I am acceptable as a human being with good, bad and neutral points”).

Discomfort tolerance This stems from the rational belief, “I want to feel comfortable and have comfortable life conditions, but I don’t need to have such com- fort in my life”. Conclusions that stem from this premise are (a) “It’s bad, but not awful when these life conditions do not exist” and (b) “I can stand the discomfort when these life conditions do not exist and it is worth it to me to do so”. Discomfort tolerance is central to dealing with a range of psychological problems and is a hallmark of what is known as psychological resilience (Reivich and Shatte, 2002 ) in that it encourages people to face up to life adversities and cope with them head on, with diff culty to be sure, particularly in the short term, but ultimately to good effect in the longer term. Discom- fort tolerance also encourages people to work hard and to be persistent in effecting productive psychological change and its presence augurs well for change in psychotherapy. Finally, discomfort tolerance forms the basis of a philosophy of long-range hedonism: the pursuit of mean- Downloaded by [New York University] at 06:45 14 August 2016 ingful long-term goals while tolerating the deprivation of attractive short-term goals, which are self-defeating in the longer term. According to REBT theory, exible beliefs about people either involve ego health (for example, “I would like you to approve of me but you don’t have to do so and if you don’t I can still accept

47 RATIONAL EMOTIVE BEHAVIOUR THERAPY

myself”) or discomfort tolerance (“I want you to approve of me and give me what I must have, but you don’t have to do so. If you don’t, I can bear it”), and thus do not represent a distinct form of psychological health since they include one or other of the two fundamental types of psychological health.

Approach 2: Self-related, other-related and life-related disturbance and health

In his later writings, Ellis moved away from emphasizing the distinction between ego and discomfort disturbance and health towards distinguishing between what I have called here self-related, other- related and life-related disturbance and health (e.g. Ellis, 2004 ). My view is that Ellis did this to capitalize on CBT’s current interest in acceptance as a curative factor in bringing about therapeutic change.

USA, UOA and ULA Drawing on his penchant for mnemonics, Ellis ( 2004 ) argued that a fundamental goal of REBT is to promote three types of acceptance: USA (unconditional self-acceptance), UOA (unconditional other-acceptance) and ULA (unconditional life-acceptance). I have already discussed these three forms of acceptance as non-extreme belief derivatives from exible beliefs in Chapter 5 .

SD, OD and LD Extrapolating from Ellis’s views on USA, UOA and ULA, we can say that REBT therapists now target three major problems for change:

• SD (self-depreciation) where the person is depreciating him- or Downloaded by [New York University] at 06:45 14 August 2016 herself in some way • OD (other-depreciation) where the person is depreciating another person or persons in some way • LD (life-depreciation) where the person is depreciating life in some way.

48 DISTINCTION BETWEEN EGO DISTURBANCE AND HEALTH

W hether one conceptualizes disturbance and health in terms of self vs. discomfort or in terms of its focus on self, other and life, it is my view that a distinctive and enduring feature of REBT is that both of these are deemed to stem from rigid beliefs and exible beliefs, respectively, about:

1 . e go and discomfort 2. self, other(s) or life. I have stressed this in Chapters 4 and 5 .

Approach 3: Disturbance and health matrices

While the above two approaches cover similar ground, they are not identical. Dryden, Gordon and Neenan ( 1997 ) have made an attempt to integrate both these approaches by using 3 x 2 disturbance and health matrices.

The 3 x 2 disturbance matrix Dryden et al. ( 1997 ) argued that it is possible to take the three basic rigid beliefs (about self, others and life) and the two fundamental disturbances (i.e. ego and discomfort) to form a 3 x 2 disturbance matrix (see Figure 10.1) . I will now discuss the six types of disturbance yielded by this matrix.

A) Ego disturbance – Rigid beliefs held about self In this type of disturbance, it is quite clear that the person concerned holds rigid beliefs about herself (in this case) and the main issue

Downloaded by [New York University] at 06:45 14 August 2016 is her attitude towards herself. The major derivative from the rigid belief is some aspect of self-depreciation, for example:

• “I must do well in my exams and if I don’t, I’m no good.” • “I must be loved and approved by certain people in my life, and if I’m not, that proves I’m no good.”

49 RATIONAL EMOTIVE BEHAVIOUR THERAPY

Ego Discomfort I must . . . AB You must . . . C D Life must . . . E F

Figure 10.1 The 3 x 2 disturbance matrix

B) Discomfort disturbance – Rigid beliefs held about self Here, the person holds rigid beliefs about herself, but the real issue concerns her attitude towards discomfort. For example:

• “If I don’t obtain my degree, I might have to settle for some kind of tedious, manual job. I must achieve more than this and couldn’t stand the hardship if I don’t.”

C) Ego disturbance – Rigid beliefs held about others In this example, the person is holding rigid beliefs about the behaviour (or its absence) of another, but the real issue centres round her attitude towards herself. This often occurs when the person is angry about the other person because that person’s behaviour constitutes a threat to her self-esteem. For example:

• “If you don’t treat me nicely, it proves that you don’t think much of me. You must think well of me and if you don’t, it means that I am no longer any good as a person.”

D) Discomfort disturbance – Rigid beliefs held about others Downloaded by [New York University] at 06:45 14 August 2016 Here, the person is holding rigid beliefs about others, but the real issue concerns the realm of discomfort. For example: • “You must treat me nicely and look after me. I couldn’t stand the hard life I’d be faced with if you do not.” 50 DISTINCTION BETWEEN EGO DISTURBANCE AND HEALTH

E) Ego disturbance – Rigid beliefs held about life conditions On the surface, the person is holding rigid beliefs about some aspects of life conditions, but the real issue concerns her attitude towards herself. For example: • “Life conditions under which I live must be easy for me. If they are not then that’s just proof of my own worthlessness.”

F) Discomfort disturbance – Rigid beliefs held about life conditions In this nal kind of disturbance, we are dealing with a more impersonal form of discomfort intolerance. This type of discomfort is frequently seen when people lose their temper with inanimate objects or in situations requiring a fair amount of patience. For example: • “I must not be frustrated by my car breaking down when I’m just about to use it. I am so frustrated, I cannot stand it.” • “When I join a queue for some service, I must be served quickly. I can’t stand delays in getting what I want.”

The 3 x 2 health matrix Extrapolating from the Dryden et al. (1997 ) 3 × 2 disturbance matrix, it is possible to develop a 3 × 2 health matrix (see Fi gure 10.2). I will now discuss the six types of health yielded by this matrix.

A) Ego health – Flexible beliefs held about self Here, the person concerned holds exible beliefs about herself and

Downloaded by [New York University] at 06:45 14 August 2016 the main derivative from this exible belief is some aspect of unconditional self-acceptance, for example: • “I would like to do well in my exams, but I don’t have to do so. If I don’t, I can accept myself as a fallible human being who is not doing as well as she likes.” 51 RATIONAL EMOTIVE BEHAVIOUR THERAPY

Ego Discomfort I want . . . but I AB don’t have to I want you to . . . but CD you don’t have to . . . I want life to . . . but EF it doesn’t have to . . .

Figure 10.2 The 3 x 2 health matrix

• “I want to be loved and approved by certain people in my life, but I don’t have to be. If I am not, that’s a shame but it does not prove I’m no good. I am the same person whether I am loved and approved or not.”

B) Discomfort tolerance – Flexible beliefs held about self Here, the person holds exible beliefs about herself, but the real issue concerns her attitude towards discomfort. For example:

• “If I don’t obtain my degree, I might have to settle for some kind of tedious, manual job. I want to achieve more than this, but I don’t have to do so. If I don’t, it would be a struggle for me to tolerate the hardship, but I could bear it and it would be worth it to me to do so.”

C) Ego health – Flexible beliefs held about others In this example, the person holds exible beliefs about the behaviour (or its absence) of another, but the real issue centres round her attitude towards herself. For example: Downloaded by [New York University] at 06:45 14 August 2016 • “If you don’t treat me, it means that you don’t think much of me. I would like you to think well of me, but you don’t have to do so. If you don’t, I can still accept myself as a person.”

52 DISTINCTION BETWEEN EGO DISTURBANCE AND HEALTH

D) Discomfort tolerance – Flexible beliefs held about others Here, the person holds exible beliefs about others, but the real issue concerns the realm of discomfort. For example: • “I want you to treat me nicely, but you don’t have to do so. If you don’t, it would be diff cult for me to put up with the hard life I’d be faced with, but I can do so and it is worth it to me to do so.”

E) Ego health – Flexible beliefs held about life conditions On the surface, the person is holding exible beliefs about some aspects of life conditions, but the real issue concerns her attitude towards herself. For example: • “I want life conditions under which I live to be easy for me, but it doesn’t have to be that way. If they are not easy then that does not prove that I am worthless. I can accept myself whatever life conditions I face.’’

F) Discomfort tolerance – Flexible beliefs held about life conditions In this nal type of health, we are dealing with a more impersonal form of discomfort tolerance. For example:

• “I don’t want the frustration of my car breaking down when I’m just about to use it, but I don’t have to have my desires met. If it did break down, that would be a pain, but I could stand the frustration if it did.” Downloaded by [New York University] at 06:45 14 August 2016 • “When I join a queue for some service, I want to be served quickly, but I don’t have to be. Although it is a struggle, I can stand delays in getting what I want and it is worth it to me to do so.”

53 This page intentionally left blank Downloaded by [New York University] at 06:45 14 August 2016 FOCUS ON META-PSYCHOLOGICAL DISTURBANCE 11

Focus on meta-psychological disturbance

While other approaches to CBT do recognize that people disturb themselves about their disturbances, none focuses on this phenom- enon as much as REBT. The fact that humans disturb themselves about their disturbance has been variously referred to as symptom stress (Walen, DiGiuseppe and Wessler, 1980) , problems about problems and meta-emotional disturbance, which literally means emotional disturbance about emotional disturbance (e.g. Dryden, 2002). If we consider the concept of meta-psychological disturbance more closely, we nd that it has a number of different features. It involves people disturbing themselves about their disturbed reactions (i.e. their unhealthy negative emotions, their unconstructive behaviour or action tendencies and/or their troublesome cognitions). They can either disturb themselves about the fact that they have had these reactions or, more normally, about the inferences that they make about these reactions. In the latter case, these inferences are made once the person holds rigid beliefs about the reactions and where these reactions have inferential meaning for the person. Let me discuss this at greater length.

Disturbed reactions at “A”; Disturbed reactions at “C”: No inferential meaning

When we disturb ourselves at “C1” about the adversities in our lives

Downloaded by [New York University] at 06:45 14 August 2016 at “A1”, we can then focus on these disturbed reactions (emotional behavioural and/or cognitive) and disturb ourselves about them. When we do this, these disturbed reactions, which were originally located at “C1”, become adversities at “A2” and our disturbed responses to them are located at “C2”. This is shown below:

55 RATIONAL EMOTIVE BEHAVIOUR THERAPY

A1 = Original adversity

B1 = Irrational belief

C1 = Disturbed reaction 1 (emotional, behavioural, cognitive)

A2 = Disturbed reaction 1 (emotional, behavioural and/or cognitive)

B2 = Irrational belief

C2 = Disturbed reaction 2 (emotional, behavioural, cognitive) – Increase of the extent of the original disturbed reaction at C1. No inferential meaning concerning A2

For example, Joe was anxious about going blank when giving a seminar paper in class, so he over-prepared what he was going to say, but at the same time he ruminated about going blank. While Joe could have disturbed about any (or all of these disturbed reactions, he actually disturbed himself about his anxiety (UNE):

A1 = I will go blank when giving my seminar talk

B1 = My mind must not go blank

C1 = Anxiety (emotional) Over-preparing (behavioural) Ruminating about going blank (cognitive)

A2 = Focus on anxiety

Downloaded by [New York University] at 06:45 14 August 2016 B2 = I must not be anxious

C2 = Increased anxiety (emotional) Staying up all night to get things right (behavioural) Paralyzed about mind going blank (cognitive)

56 FOCUS ON META-PSYCHOLOGICAL DISTURBANCE

In this type of meta-psychological disturbance where the person holds irrational beliefs about the reactions but where there is no inferential meaning involved, what tends to happen, as shown in the example, is that there is an increase in the extent of the meta- psychological disturbance related to the original disturbance.

Inferences about disturbed reactions at “A”; Disturbed reactions at “C”

As I said earlier, meta-psychological disturbance occurs more frequently when people make inferences about their original disturbed reactions rather than about the disturbed reactions themselves. These inferences arise when the person holds irrational beliefs about the original disturbance (e.g. “I must not feel this way”) and are generally, therefore cognitive consequences of this second level of irrational beliefs. These inferences may be made about the unhealthy negative emotions, unconstructive behaviour or action tendencies and/or distorted cognitions that comprise their original disturbance.

Inferences about UNEs at “A”; Disturbed reactions at “C” W hen we disturb ourselves at “C1” about the adversities in our lives at “A1”, we can then focus on the emotional aspect of our disturbance (known in REBT as unhealthy negative emotions or UNEs) and hold irrational beliefs about these UNEs. The cognitive consequences of this disturbance take the form of inferences about these UNEs and we then disturb ourselves about these inferences. When we do this, these UNEs, which were originally located at “C1” and A2, become adversities at “A3” due to the inferences that we make about them and our disturbed emotional, behavioural and cognitive responses to them are Downloaded by [New York University] at 06:45 14 August 2016 located at “C3”. This is shown here:

A1 = Original adversity

B1 = Irrational belief

57 RATIONAL EMOTIVE BEHAVIOUR THERAPY

C1 = UNE

A2 = UNE B2 = Irrational belief

C2 = Disturbed reaction (emotional, behavioural, cognitive = inference about UNE)

A3 = Inference about UNE B3 = Irrational belief

C3 = Disturbed reaction (emotional, behavioural and cognitive)

For example, let’s suppose that Jane felt anxious about giving a poor public speech. She then disturbed herself about this anxiety because of the irrational beliefs that she held about it. As a result of these irrational beliefs, she inferred that her anxiety meant that she was losing control, which she then disturbed her as shown below:

A1 = Doing poorly at public speech B1 = Irrational belief C1 = Anxiety

A2 = Focus on anxiety Downloaded by [New York University] at 06:45 14 August 2016 B2 = Irrational belief (“I must not feel anxiety”) C2 = Inference “This anxiety means that I am losing control”

58 FOCUS ON META-PSYCHOLOGICAL DISTURBANCE

A2 = Losing control (inference about C2)

B2 = Irrational belief (“I must regain control immediately”)

C2 = Increased anxiety (emotional) Drinking alcohol to gain immediate control (behavioural) Images of falling apart (cognitive)

Common inferences that people make about their original unhealthy negative emotions about which they hold irrational beliefs and about which they then disturb themselves about include: • being out of control • being weak • having a character aw • being nasty • breaking a personal rule • going mad • being judged negatively by others • negative impact on future career prospects.

Inferences about behaviours or action tendencies at “A”; Disturbed reactions at “C” S imilarly, we can also disturb ourselves about the behavioural components of our original disturbance. Thus:

A1 = Original adversity

B1 = Irrational belief

C1 = Unconstructive behaviour or action tendency Downloaded by [New York University] at 06:45 14 August 2016

A2 = Unconstructive behaviour or action tendency

B2 = Irrational belief

59 RATIONAL EMOTIVE BEHAVIOUR THERAPY

C2 = Disturbed reaction (emotional, behavioural, cognitive – inference about unconstructive behaviour or action tendency)

A3 = Inference about unconstructive behaviour or action tendency

B3 = Irrational belief C3 = Disturbed reaction (emotional, behavioural, cognitive)

For example, Harold made himself unhealthily angry when someone cut across him while driving and when he was angry he made a racist remark at the driver. He then focused on what he said and disturbed himself about it, the cognitive component of which was the inference that he fell very short of the standards he set for himself. He then disturbed about (felt ashamed) about this falling short as shown below:

A1 = Someone broke my rule by cutting me up while I was driving B1 = Irrational belief

C1 = Shouted racist remarks at the driver while unhealthily angry

A2 = Focus on shouting racist remarks B2 = Irrational beliefs about behaviour (I absolutely should not have acted in the way that I did)

C2 = Inference = This behaviour means that I have fallen very

Downloaded by [New York University] at 06:45 14 August 2016 short of my ideals

A3 = I have fallen very short of my standards by making racist remarks (inference about C2) 60 FOCUS ON META-PSYCHOLOGICAL DISTURBANCE

B3 = Irrational belief (I absolutely should not fall short of my ideals)

C3 = Shame (emotional) Not driving in that area again (behavioural) Images of being publicly shunned for racism (cognitive)

Inferences about thoughts at “A”; Disturbed reactions at “C” Finally, we can disturb ourselves about the cognitive components of our original disturbance. Thus:

A1 = Original adversity

B1 = Irrational belief

C1 = Distorted cognitions

A2 = Distorted cognitions

B2 = Irrational belief

C2 = Disturbed reaction (emotional, behavioural, cognitive inference about distorted cognitions)

A3 = Inference about distorted cognitions

B3 = Irrational belief

Downloaded by [New York University] at 06:45 14 August 2016 C3 = Disturbed reaction (emotional, behavioural, cognitive)

For example, Carl felt unhealthily envious about his best friend having a prettier girlfriend than he had. As part of his unhealthy envy, Carl had the thought of throwing acid into his friend’s girlfriend’s face. He then focused on this thought and inferred that it meant that

61 RATIONAL EMOTIVE BEHAVIOUR THERAPY

he was beginning to go mad and disturbed himself about this as shown below:

A1 = My friend’s girlfriend is prettier than mine

B1 = Irrational belief

C1 = Thinking of throwing acid in friend’s girlfriend’s face when unhealthily envious

A2 = Focus on thinking of throwing acid in friend’s girlfriend’s face when unhealthily envious

B2 = Irrational belief (“I must not think such a thing”)

C2 = These thoughts mean that I am going mad

A3 = These thoughts mean that I am beginning to go mad

B3 = Irrational belief (“I must not have any mad thoughts”)

C3 = Anxiety (emotional) Avoidance of friend and his girlfriend (behavioural) Images of self in a straitjacket in a psychiatric hospital (cognitive)

I t w ill be seen that there are three levels of disturbance when inferential meaning is involved. While I am not suggesting that these three levels are taught to clients – level two can often be omitted – it is

Downloaded by [New York University] at 06:45 14 August 2016 useful to help clients to understand that the inferences that they form about their original disturbances often stem from the rigid demand that they must not feel/act/think in the ways in which they did (see also Chapter 8). Helping clients to form exible beliefs about these feelings, behaviour and thinking tends to encourage them to form healthier inferences about their original disturbed reactions. 62 BIOLOGICAL BASIS OF HUMAN IRRATIONALITY 12

The biological basis of human irrationality

Ellis ( 1976 ) argued that humans have two basic biological tendencies. First, we have a tendency towards irrationality i.e. we naturally tend to make ourselves disturbed. Second, we have a tendency towards becoming aware of our irrationality and towards working steadily towards rationality. Ellis ( 1976 ) noted that this second tendency requires more effort than the rst! E llis ( 1976 ) made a number of points in support of this “biological hypothesis”. These included the following.

Human irrationality is ubiquitous

Virtually all humans show evidence of major human irrationalities. Thus, virtually all of us disturb ourselves about life’s adversities. Of course, we do not disturb ourselves about the same adversities and the extent of our disturbance will vary from person to person, but virtually all of us do this. Our disturbance does not interfere with the survival of the species and most of the time it does not interfere with our individual existence. As Ellis often used to say, “Mother nature is concerned with our survival not with the emotional quality of our life.” The latter is rmly within our responsibility and the fact that many of us needlessly disturb ourselves shows that this tendency is rooted in our humanity. Conversely, consider how different our lives would be if human Downloaded by [New York University] at 06:45 14 August 2016 rationality were as ubiquitous as human irrationality appears to be. It would be very diff cult for us to disturb ourselves about life’s adversities. We would rarely procrastinate and would persist at striving towards our goals. We would be very self-disciplined and would live longer because we would rarely smoke and would tend

63 RATIONAL EMOTIVE BEHAVIOUR THERAPY

to keep to healthy eating regimes. This is obviously not the case and although we have the ability to think and act rationally, the fact that we nd it hard to sustain doing so is evidence for Ellis’s (1976 ) view that there is a strong biological basis to human irrationality.

Ease in thinking in rigid and extreme ways

Earlier in this book, I distinguished between exible beliefs and non- extreme beliefs, on the one hand, and rigid and extreme beliefs, on the other. I commented that REBT theory posited that rigid and extreme beliefs are at the core of psychological disturbance and that exible and non-extreme beliefs are at the core of psychological health. I showed, in particular, that both rigid beliefs and exible beliefs are very frequently based on our desires, but what distinguishes them is when we hold rigid beliefs we transform these desires into rigid, absolute necessities, but when we hold exible beliefs we keep our desires exible and acknowledge to ourselves that we do not have to have our desires met. I also showed that extreme and non-extreme beliefs stem from rigid and exible beliefs respectively. Now, REBT theory holds that when our desires are weak then we nd it relatively easy to keep our beliefs exible and non-extreme when our desires are not met. However, when our desires become stronger and particularly when they are very strong, then we nd it very much more diff cult to retain exibility and non-extremity in our beliefs. In other words, when our desires are strong, then we nd it relatively easy to transform these desires into absolute necessities and the fact that it is bad and tolerable when we don’t get what we want into the idea that it is awful and unbearable to be thus thwarted. Again, the ease with which most humans do this points to the biological underpinnings of this common form of human irrationality.

Downloaded by [New York University] at 06:45 14 August 2016 If we were strongly biologically prone to retain exible and non- extreme beliefs in the face of our very strong desires not being met, then we would nd it very diff cult to think in rigid and extreme ways under these circumstances and would tend not to do so even if strongly encouraged to do so by our culture.

64 BIOLOGICAL BASIS OF HUMAN IRRATIONALITY

For example, let’s suppose that I hold a weak desire about being picked by my college to represent it at a marketing function. If I were not picked, it would be relatively easy for me to retain exibility and non-extremity in my belief system. I would begin by saying: “It is somewhat important for me to be selected to represent my college …” and I would conclude thus, “… but I don’t have to be chosen and it is bad, but not terrible if I’m not.” However, if my desire was very strong I would struggle to retain my exible and non- extreme belief. Here, I would begin by saying: “It is really important for me to be selected to represent my college …”, however, I would then easily conclude, “and therefore I have to be selected and it would be terrible if I weren’t”. I would have to work very hard to go back and remain with my exible and non-extreme beliefs. The fact that I would have to work so hard shows that it is diff cult for me as a human to stay with my exible and non-extreme beliefs when my unmet desires are very strong. While human irrationality is ubiquitous and the tendency for humans to transform their very strong desires into rigid dire necessities and into extreme views when these desires are not met seems universal, there seems to be a good deal of individual differences in the extent and ease with which people disturb themselves. A few rarely do so and only when their thwarted desires are paramount do they transform these into rigid and extreme beliefs. By the same token, others seem to transform even very weak desires into rigidities when they don’t get what they want. This is particularly the case with people who have a severe personality disorder ( Ellis, 2002 ).

Human irrationality is taught less frequently than human rationality

Downloaded by [New York University] at 06:45 14 August 2016 Many human irrationalities actually go counter to the teachings of parents, peers and the mass media (for example, people are rarely taught that it is good to procrastinate, yet countless do so). Children are frequently told that just because they want something it doesn’t mean that they must get it. Yet despite such teachings, countless

65 RATIONAL EMOTIVE BEHAVIOUR THERAPY

people procrastinate and we all tend to demand that we have to get what we want in some area or another. If human rationality was biologically based, frequent cultural teachings about the value of anti-procrastination and non-demandingness would have a far greater impact than they seem to.

Humans easily lapse, relapse and replace one irrationality with another

While humans have a tendency to think and act irrationally, they also have a tendency to think about their thinking and behaviour and to work towards greater rationality. If we did not have the potential to be rational, then the efforts of counsellors and therapists would be in vain. However, once we have actualized our tendency to be rational, we often go back to irrational activity even though we have worked hard to overcome it (Ellis, 1976) . Thus, we frequently lapse in our efforts to become and stay rational in certain key areas. For example, we may for a while give up certain self-defeating habits, but then lapse back into these habits for a time when the going gets tough. We may even relapse and end up as irrational as we were when we rst began a programme of self-help. A lso, when we are successful at helping ourselves with our irrational thinking in one area, we may well replace this irrationality with another. Thus, some people are able to overcome their irrational thinking about smoking, but then develop irrational ideas about food. It may be that while we keep a disciplined eye in one area of our lives, we let go of such a rational perspective in other areas. A number of years ago in Britain, Boots the Chemist ran a beginning of the year campaign urging its customers to make one small change, in recognition of the failure experienced by most people in tackling Downloaded by [New York University] at 06:45 14 August 2016 several areas of poor self-discipline at once! T he ease with which we lapse and relapse, the ease with which we replace one irrationality with another and the great diff culty we have at making several changes at once, all point again to the

66 BIOLOGICAL BASIS OF HUMAN IRRATIONALITY

biological basis of this form of irrationality. As a species, we nd it inordinately diff cult to think and act rationally in the rst place and to acquire and, particularly, maintain rational thinking and action in the second place. Downloaded by [New York University] at 06:45 14 August 2016

67 This page intentionally left blank Downloaded by [New York University] at 06:45 14 August 2016 POSITION ON ORIGIN OF PSYCHOLOGICAL PROBLEMS 13

REBT’s position on the origin and maintenance of psychological problems

We have seen that one of the key theoretical principles of REBT is that summarized in the maxim that: “People are disturbed not by things, but by the rigid and extreme beliefs that they hold about things.” This means that while negative events contribute to the development of psychological disturbance, particularly when these events are highly aversive, disturbance occurs when people bring their tendencies to think irrationally to these events. REBT does not, therefore, have an elaborate view of the origin of disturbance. Having said this, it does acknowledge that it is very easy for humans when they are young to disturb themselves about highly aversive events. However, it argues that even under these conditions people react differently to the same event and thus we need to understand what a person brings to and takes from a negative activating event. People learn their standards and goals from their culture, but disturbance occurs when they bring their irrational beliefs to circumstances where their standards are not met and their pursuit of their goals is blocked. B y contrast, REBT has a more elaborate view of how psychological disturbance is maintained. It argues that people perpetuate their disturbance for a number of reasons including the following: • They lack the insight that their psychological disturbance is

Downloaded by [New York University] at 06:45 14 August 2016 underpinned by their irrational beliefs and think instead that it is caused by events. • They think that once they understand that their problems are underpinned by irrational beliefs, this understanding alone will lead to change.

69 RATIONAL EMOTIVE BEHAVIOUR THERAPY

• They do not work persistently to change their irrational beliefs and to integrate the rational alternatives to these beliefs into their belief system. • They continue to act in ways that are consistent with their irrational beliefs. • They disturb themselves about their original disturbances. • They lack or are de cient in important social skills, communi- cation skills, problem-solving skills and other life skills. • They think that their disturbance has pay-offs that outweigh the advantages of the healthy alternatives to their disturbed feelings and/or behaviour. • They live in environments that support the irrational beliefs that underpin their problems. As will be seen REBT’s view on the perpetuation of psychological disturbance informs its position on psychological change. Downloaded by [New York University] at 06:45 14 August 2016

70 REBT’S POSITION ON PSYCHOLOGICAL CHANGE 14

REBT’s position on psychological change

REBT therapists consider that the core facilitative conditions of empathy, unconditional acceptance and genuineness are often desirable, but neither necessary nor suff cient for constructive therapeutic change. For such change to take place, clients need to be helped to: • Realize that they largely create their own psychological problems and that while situations contribute to these problems, they are in general of lesser importance in the change process. • Fully recognize that they are able to address and overcome these problems. • Understand that their problems stem largely from irrational beliefs. • Detect their irrational beliefs and discriminate between them and their rational beliefs. • Examine their irrational beliefs and their rational beliefs until they see clearly that their irrational beliefs are false, illogical and unconstructive while their rational beliefs are true, sensible and constructive. • Work towards the internalization of their new rational beliefs by using a variety of cognitive (including imaginal), emotive and behavioural change methods. In particular, act in ways that are consistent with the rational beliefs that they wish to develop and refrain from acting in ways that are consistent with their old

Downloaded by [New York University] at 06:45 14 August 2016 irrational beliefs. • Extend this process of examining beliefs and using multimodal methods of change into other areas of their lives and committing to doing so for as long as necessary.

71 RATIONAL EMOTIVE BEHAVIOUR THERAPY

The importance of choice and going against the grain in psychological change

REBT theory argues that we have choice: We can choose to construct rigid and extreme ideas from our desires or we can choose to construct and remain with exible and non-extreme ideas in relation to our desires. I have already argued that we nd it very easy as humans to transform our desires into absolute necessities when these desires are strong and have a tough time being exible about the attainment of these desires. This point also applies about the ease with which we construct extreme ideas when our desires are thwarted and the diff culty we have in constructing and remaining with non-extreme ideas when our desires are unmet. However diff cult we nd it being rational (i.e. thinking exibly and in non-extreme ways) in the face of life’s adversities and/or when our strong desires are not met, REBT theory says that we can choose to construct and remain with rational ideas under these circumstances even though it goes against the grain for us to do so. This means that we can choose to think rationally even though we have a strong tendency to choose to construct and remain with irrational (i.e. rigid and extreme) ideas. This “going against the grain” thinking is diff cult to sustain without commitment, force and energy and a determination to align one’s behaviour and inferential thinking with rational beliefs, and a corresponding determination not to act and think in ways that may perpetuate our irrational beliefs. The idea that we can, with great effort, think and act rationally under very diff cult circumstances is a hallmark of REBT.

When belief change is not on the agenda

So far in this chapter, I have focused on psychological change that is underpinned by belief change. However, helping people to change

Downloaded by [New York University] at 06:45 14 August 2016 their beliefs from irrational to rational is not always feasible or desired by clients. In this case, REBT theory argues that clients can be helped by changing their inferences, their behaviour or by changing their environments. I will discuss this more fully in Chapter 26 .

72 POSITION ON GOOD MENTAL HEALTH 15

Position on good mental health

In the US TV series, at the end of his radio programme, Frasier wishes the people of Seattle “good mental health”. However, he never outlines what this is. REBT, by way of contrast, is very explicit about what constitutes good mental health, more explicit in this respect than other CBT therapies. REBT not only sees its aim as the reme- diation of psychological disturbance, it also strives to help clients to work towards being as psychologically healthy as possible. This is how REBT conceptualizes good mental health.

Personal responsibility

People with good mental health (GMH) accept full responsibility for their emotional disturbances and will strive to overcome their own emotional and behavioural problems by utilizing the methods and techniques of REBT and CBT. They acknowledge that situations and other people contribute to their disturbance, but they resist the temptation to blame their feelings on these situations/people (see C hapter 7 for a fuller discussion).

Flexibility and anti-extremism

People with GMH have a belief system made up largely of exible Downloaded by [New York University] at 06:45 14 August 2016 and non-extreme beliefs. When they do disturb themselves by holding rigid and extreme beliefs they recognize this and take steps as soon as they can to question these beliefs and to hold and act on the exible and non-extreme alternatives to these beliefs

73 RATIONAL EMOTIVE BEHAVIOUR THERAPY

As we have seen, people with GMH have desires but don’t transform them into demands on self, others and life conditions. They acknowledge badness, but don’t awfulize, they tolerate frustration and discomfort when it is in their healthy interests to do so and they accept themselves and others as fallible human beings and life as a complex mixture of the good, the bad and the neutral (see Chapter 5 for a fuller discussion). By de nition, such people are open to change and are minimally defensive.

Scientifific thinking and non-Utopian in outlook

People with GMH tend to be scienti c in their thinking. They tend to regulate their emotions and actions by re ecting on them and evalu- ating their consequences in terms of the extent to which they lead to the attainment of their short-term and long-term goals. They also see their inferences as hunches about reality rather than facts and are prepared to examine their accuracy by looking at the available evidence. T hey are also sceptical and don’t accept as true assertions that appear attractive or because an authority states that they are true. They have an independent mind. F inally, they accept the fact that Utopias are probably unachiev- able and also recognize that it is unlikely that they will get every- thing they want and that they will frequently experience frustration in their lives.

Enlightened self-interest

People with GMH tend to be rst and primarily interested in them-

Downloaded by [New York University] at 06:45 14 August 2016 selves and to put their own healthy interests at least a little above the interests of others. However, they sacri ce themselves to some degree for those for whom they care but not overwhelmingly or completely. They also show themselves as much compassion and caring as they do the signi cant others in their life.

74 POSITION ON GOOD MENTAL HEALTH

Social interest

People with GMH also realize that if they do not act morally to protect the rights of others and abet social survival, it is unlikely that they will help to create the kind of world in which they themselves can live comfortably and happily.

Self-direction

Because people with GMH take responsibility for their lives they are largely self-directing while simultaneously preferring to cooperate with others. In doing so, they do not need the support or help of others although they regard these as being desirable. They are not proud to ask for help when they need to and do not regard themselves as weak for doing so.

High tolerance of uncertainty

People with GMH have a high tolerance for uncertainty and do not demand that they must know what is going to happen to them or to others. As such, they do not act impulsively or seek reassurance when it is not appropriate to do so.

Strong commitment to meaningful pursuits

People with GMH realize that they tend to be healthier and hap- pier when they are vitally absorbed in something outside themselves. REBT does not have anything relevant to say about what these meaningful pursuits should be as there is an enormous range of such

Downloaded by [New York University] at 06:45 14 August 2016 activities available to people. In this area, it encourages people to be themselves and go for what they nd meaningful no matter how strange this may appear to others, although it also encourages others to be mindful of the reactions of others (see the section on social interest above).

75 RATIONAL EMOTIVE BEHAVIOUR THERAPY

Calculated risk taking

People with GMH tend to take a fair number of risks and try to do what they want to do even where there’s a good chance that they might fail. They tend to be adventurous but not foolhardy in this respect and act on the maxim: nothing ventured, nothing gained, or as my mother used to say, “If you don’t ask, you don’t get!”

Long-range hedonism

People with GMH are willing to forgo short-term pleasures when these interfere with the pursuit of their long-term constructive goals. In this respect, they have a philosophy of discomfort tolerance by showing that they do not have to get what they want immediately and can unrebelliously buckle down to doing necessary but boring tasks when it is in their best interests to do so promptly. REBT, however, is no killjoy therapy. It also believes that people with GMH are passionate individuals who like to enjoy themselves. Thus, REBT encourages people to go for immediate pleasure when doing so has no adverse long-term implications. Downloaded by [New York University] at 06:45 14 August 2016

76 Part 2

THE DISTINCTIVE PRACTICAL FEATURES OF REBT Downloaded by [New York University] at 06:45 14 August 2016 This page intentionally left blank Downloaded by [New York University] at 06:45 14 August 2016 THE THERAPEUTIC RELATIONSHIP IN REBT 16

The therapeutic relationship in REBT

The consensus view in the cognitive-behaviour therapies is that the core conditions outlined many years ago by Carl Rogers ( 1957 )— namely, empathy, respect and genuineness—are solid foundations for therapeutic change, but are neither necessary nor suff cient for change to occur. REBT concurs with this view, but also outlines some distinct contributions to the therapeutic relationship that will be the focus of the present discussion.

Therapist warmth

E llis (in Dryden, 1997 ) argued that while most other therapeutic approaches encourage therapists to be warm towards their clients, REBT advocates therapists giving unconditional acceptance rather than giving warmth or approval to clients. Other cognitive- behavioural approaches to therapy tend not to make this distinction. Ellis held that therapist warmth and approval have their distinct dangers in that they may unwittingly encourage clients to strengthen their dire needs for love and approval.

Therapist acceptance

In his original formulation, Rogers (1957 ) argued that it is an impor- Downloaded by [New York University] at 06:45 14 August 2016 tant therapeutic ingredient for therapists to be experienced by their clients as showing them positive regard for them. This concept of positive regard has also been referred to by person-centred therapists as “prizing” and “respect”. What unites these concepts is that the

79 RATIONAL EMOTIVE BEHAVIOUR THERAPY

therapists convey that they regard clients as persons of worth and that they do this unconditionally. You will see that this is akin to the concept of unconditional worth discussed in C hapter 9. Other CBT therapists would concur with this idea of therapists showing clients unconditional respect. While REBT therapists would not disagree with this idea, we prefer showing our clients that we unconditionally accept them as fallible human beings who are neither worthwhile nor worthless since they are far too complex to be given a single evaluation and, in any respect, are constantly in ux, which would soon render such single ratings out of date even if they were legitimate, which they are not. This stance is consistent with REBT’s position on human worth, which I discussed in Chapter 9 .

Informality

REBT therapists tend towards informality of therapeutic style although we can be formal when required. This informality com- municates a number of messages to clients. First, it says that REBT therapists take themselves and their role seriously, but not too seriously. Second, informality tends to lessen the emotional distance between therapist and client without losing sight of the fact that this relationship has been established to help the client to achieve their therapeutic goals. Third, it tends to communicate therapeutic parity between therapist and client. Actually, REBT’s position on parity in therapy is as follows. When it comes to the business of conceptualizing clients’ problems and effecting change in these problems, REBT therapists are decid- edly superior to their clients, or at least (ideally) should be. How- ever, when it comes to their value as human beings, then REBT’s

Downloaded by [New York University] at 06:45 14 August 2016 position is that they are equivalent in value because they are both, fallible, ever-changing human beings far too complex to merit a single rating such as value or worth!

80 THE THERAPEUTIC RELATIONSHIP IN REBT

Humour T here is a consensus view in REBT that therapist humour is an effective part of the therapeutic relationship between therapist and client. Certainly therapist humour is emphasized more heavily in REBT than in other CBT approaches. Therapist humour should be focused on aspects of clients rather than directed at the clients themselves and should have the quality of laughing with clients rather than laughing at clients. The use of humour in REBT stems from Ellis’s ( 1987 ) view that one way of looking at psychological disturbance is that it occurs when people take themselves, other people and/or life conditions not just seriously, but too seriously. Therapist humour is effective when it encourages clients to stand back and see the ridiculous in their thinking and behaviour and when it promotes a determination to think and act rationally. As with other interventions, REBT therapists should not use humour with all clients, and it is worth noting in passing that not all REBT therapists have the capacity to use humour effectively in therapy. Downloaded by [New York University] at 06:45 14 August 2016

81 This page intentionally left blank Downloaded by [New York University] at 06:45 14 August 2016 POSITION ON CASE FORMULATION 17

Position on case formulation

Persons ( 1989 ), in a seminal book, highlighted the importance of adopting a case formulation approach to the practice of CBT. A case formulation (sometimes called case conceptualization) is essentially a blueprint, which takes as its starting point a client’s presenting problems and puts forward hypotheses about factors that account for these problems and explain how the client unwittingly perpetuates these problems. These factors are mainly cognitive and behavioural, but environmental and interpersonal context factors are also included. A good case formulation also considers the relationships between a client’s problems and possible obstacles to progress and suggests a pragmatic order in which to tackle the person’s problems. In short, it provides order to the conceptualization and treatment of the client’s problems. Currently, most CBT therapists carry out a formulation of a “case” before embarking on treatment unless the need is pressing to treat a client before such a formulation is undertaken. When case formulation is carried out in CBT, it is done so collaboratively. As I discussed in C hapter 3, REBT therapists use an ABC framework to help ourselves and our clients understand the cognitive- behavioural dynamics of the clients’ target problems. This also happens in CBT although what factors are included in a CBT-based ABC assessment may differ in several respects to one carried out in REBT. What we do not routinely do is to wait to intervene on our Downloaded by [New York University] at 06:45 14 August 2016 clients’ problems until we have carried out a case formulation. Thus, REBT therapists tend to intervene more quickly on a client’s target problem and build up a “formulation of the case” as they go rather than structuring therapy into formulation-intervention stages.

83 RATIONAL EMOTIVE BEHAVIOUR THERAPY

As with many other issues, the views of Albert Ellis are the driving force here. When he started his career he became dissatis- ed with an approach to therapy that saw therapeutic intervention being dependent on a thorough assessment of clients’ psychopathol- ogy and personality based on the completion and analysis of a large number of questionnaires, inventories and other assessment tools. Ellis (1962 ) regarded this process as ineff cient and noted that a signi cant number of clients tended to drop out of this process before treatment had commenced. Ellis noted the waste of therapist, client and an organization’s time when many person hours were spent on preparing the client for an intervention based on the accumulation and analysis of these data that was subsequently not made because the client had dropped out before treatment proper had commenced. The legacy of this experience was that Ellis considered it to be the best use of everyone’s time and resources if treatment was got- ten underway as quickly as possible. Hence, Ellis tended to eschew a case formulation approach to REBT, where a formal formulation routinely precedes treatment. Of course, Ellis was a highly skilled formulator of “cases”, as anyone who had received clinical supervi- sion from him will testify. But he tended to do this in his head rather than on paper and, as noted above, he made his formulations during therapy rather than before therapy had got underway. Indeed, Ellis argued that a client’s response to therapy tells the therapist a great deal about the client and their problems and for this to become mani- fest, therapy must be initiated. So, what have other REBT therapists had to say about the use of case formulation in REBT? I have perhaps put forward the most developed approach to the use of a case formulation in REBT (Dryden, 1998) . I call this approach UPCP, which stands for “understanding the person in the context of his or her problems’’ because I dislike referring to a person as a “case”.

Downloaded by [New York University] at 06:45 14 August 2016 I argue that there are number of factors that need to be identi ed when conducting a UPCP: 1. Basic information on the client and any striking initial impressions. 2. A list of the client’s problems.

84 POSITION ON CASE FORMULATION

3 . T he client’s goals for change. 4. A list of the client’s problem emotions (UNEs). 5. A list of the client’s problem critical “A”s (e.g. disapproval, uncertainty, failure, injustice). 6 . T he client’s core irrational (rigid and extreme) beliefs. 7. A list of the client’s dysfunctional behaviours. 8. The purposive nature of dysfunctional behaviour. 9. A list of the ways in which the client prevents or cuts short the experience of their problems. 10. A list of the ways in which the client compensates and/overcom- pensates for problems. 11. A list of meta-psychological problems (see Chapter 11 ). 12. A list of the cognitive consequences of core irrational beliefs. 13. How the client expresses problems and the interpersonal responses to these expressions. 14. T h e client’s health and medication status. 15. A list of relevant predisposing factors. 16. Predicting the client’s likely responses to therapy. As you can see from the above, developing a UPCP takes time and this time may be better spent in helping the client to address their problems. Thus, I do not recommend that REBT therapists carry out a full UPCP with every client. But it should be conducted: • When it is clear that the person has many complex problems. • When resistance occurs in clients who have at rst sight non- complex problems and where usual ways of addressing such resistance have proved unsuccessful. • When clients have had several unsuccessful previous attempts at therapy, particularly REBT. Downloaded by [New York University] at 06:45 14 August 2016

85 This page intentionally left blank Downloaded by [New York University] at 06:45 14 August 2016 PSYCHO-EDUCATIONAL EMPHASIS 18

Psycho-educational emphasis

Ellis and Dryden ( 1997 ) argued that REBT can usefully be viewed as a psycho-educational approach to therapy. In this respect, REBT has a decided view of the nature of psychological disturbance and how this can be addressed and many of its practitioners largely hold the view that both can be actively taught to clients. Such teaching occurs in all the major therapeutic arenas (individual, couple, family, group) as well as contexts that may be less associated with therapy: workshops for the public and nine-hour intensives (Ellis and Dryden, 1997 ).

What do we teach our clients in REBT?

In REBT, we teach our clients a range of issues. For example: 1. We teach them at the outset about the essence of REBT and about what they can realistically expect from their therapist and what their therapist can realistically expect from them. Thus we teach them: • That life’s adversities do not disturb them. Rather, they disturb themselves about life’s adversities. • That they disturb themselves because they hold irrational (i.e. rigid and extreme) beliefs about life’s adversities. • What tasks their therapists are likely to carry out in therapy. Downloaded by [New York University] at 06:45 14 August 2016 • What tasks they will in all likelihood be called on to carry out in the process. Once we have taught them the above they are in a position to give (or withhold) their informed consent to proceed as a client in REBT.

87 RATIONAL EMOTIVE BEHAVIOUR THERAPY

2. We teach them the dynamics of unhealthy negative emotions. We show them that each disturbed emotion has typical inferences at “A”, irrational (i.e. rigid and extreme) beliefs at “B” and recurring behaviours and thinking consequences at “C”. 3. We teach them how to identify their problems and set realistic, achievable goals for each of these problems. 4. We teach them to select a target problem at a given point in time and to assess this problem accurately using the ABC framework (see Chapter 3 in this book). 5. We teach them to identify any secondary meta-psychological problems (see Chapter 11 ) that they may have and to decide whether or not it is better for them to target this problem before their primary problem. 6. We teach them that in order for them to un-disturb themselves about life’s adversities in general and about the adversity they are focusing on in particular, they need to change their beliefs about these adversities from irrational (i.e. rigid and extreme) to rational (i.e. exible and non-extreme). 7. We teach them that in order for them to change their irrational beliefs to rational beliefs they rst need to ask questions that are targeted at the empirical, logical and pragmatic status of these beliefs. In doing so, we teach them how to frame such questions to get the most out of this process. They are advised to do this until they can see why their irrational beliefs are irrational and why their rational beliefs are rational. When they reach this stage they are said to have achieved intellectual insight into the irrationality of their irrational belief and into the rationality of their rational beliefs. Such insight is the foundation of change but does not in itself promote it. Here clients typically say: “I understand it in my head, but not in my gut.”

Downloaded by [New York University] at 06:45 14 August 2016 8. We teach them that once they have achieved intellectual insight, they have to use a variety of methods to facilitate emotional insight. It is this insight that leads to clients changing their feelings. We also train them how to use these techniques.

88 PSYCHO-EDUCATIONAL EMPHASIS

9. We teach clients how they unwittingly perpetuate their problems and what they need to do to break the perpetuation cycle (see Chapter 13 ). 10. Once they have made progress, we teach clients what they need to do to minimize the chances of lapsing and relapsing. 11. We teach them how to generalize their learning from one problem to another and later in therapy we teach them what they need to do to become their own therapists.

How is this teaching delivered?

REBT therapists agree with their cognitive therapy colleagues that it is best for clients to be helped to discover for themselves how they disturb themselves cognitively and how they can stand back and question these disturbance-creating cognitions. It is best because self-discovery and the independent thinking that underpins it is an important criterion of good mental health (GMH)—see Chapter 15. In this regard, both CT and REBT therapists employ Socratic questions to help their clients in this regard. In Socratic questioning, therapists ask their clients open-ended questions and guide them to discover which cognitions are at the root of their problems and how to evaluate and change them. It does not involve therapists didactically telling clients why their cognitions are problematic and how to change them. While REBT therapists favour Socratic methods of teaching in that they encourage independent thinking, we accept that at times we will also have to be didactic when clients do not understand a point through Socratic enquiry. We also acknowledge that some clients do not respond at all well to Socratic methods of teaching but do respond much better to didactic methods and, consequently, we are quite prepared to work didactically with such clients,

Downloaded by [New York University] at 06:45 14 August 2016 more so than our cognitive therapy colleagues. Flexibility of teaching approach is valued, tailoring the teaching method to the client. Some REBT therapists argue that their prime role is not to help clients to address their emotional problems, but to teach clients to

89 RATIONAL EMOTIVE BEHAVIOUR THERAPY

become pro cient at using REBT change-based methods so they can address their own emotional problems. To this end, these latter REBT therapists use materials to facilitate skill development (e.g. Dryden, 2001 ).

Emphasis on client learning

So far I have focused on the teaching aspect of the psycho- educational approach to REBT. However, no matter how well therapists teach clients REBT concepts the important aspect is what these clients learn from teaching efforts. Given this, it is crucial that therapists elicit feedback from clients concerning what they have learned from what they have been taught. Consequently, after a teaching episode a typical question that an REBT therapist asks their client is: “I am not sure that I have made myself clear, can you put into your own words the point that I have made?” While it is important for therapists to ensure that clients accurately learn what they have been taught, it is equally important for therapists to assess their clients’ reactions to these teachings. Thus, a client may accurately understand an REBT concept but not see its therapeutic value or may have some doubts, reservations or objections to it (see C hapter 28 for a more detailed discussion of such doubts, etc.). In such cases, the therapist would address the client’s point as fully as possible without threatening their working alliance. In the nal analysis, if a client does not nd a concept useful or has enduring objections to it, the therapist would not press for the client to use it and would nd a suitable alternative for the client to consider. Downloaded by [New York University] at 06:45 14 August 2016

90 DEALING WITH PROBLEMS IN ORDER 19

Dealing with problems in order: (i) Disturbance; (ii) Dissatisfaction; (iii) Development

C lients come to REBT with a variety of problems: (i) emotional problems; (ii) practical problems with which they are dissatis ed; and (iii) personal development problems. A distinctive feature of REBT is that it outlines a logical order for dealing with these problems. Thus, it argues that, whenever possible, therapists and clients target the latter’s emotional problems before their dissatisfaction-based practical problems and dissatisfaction-based practical problems before issues of personal development.

Disturbance before dissatisfaction

REBT argues that unless there are good reasons to the contrary, it is best to help clients address their emotional problems before their dissatisfaction problems. The reasoning is as follows. If clients try and deal with their dissatisfaction before they deal with their emotional disturbance, then their disturbed feelings will get in the way of their efforts to change directly the negative “A”s about which they are dissatis ed. For example, let’s take the example of Paul who is dissatis ed about his wife’s spending habits. However, he is also unhealthily angry about her behaviour and every time he talks to her about it he Downloaded by [New York University] at 06:45 14 August 2016 makes himself angry about it, raises his voice to his wife and makes pejorative remarks about her and her spending behaviour. Now what is the likely impact of Paul’s expression of unhealthy anger on his wife? Does it encourage her to stand back and look objectively at

91 RATIONAL EMOTIVE BEHAVIOUR THERAPY

her own behaviour? Of course it doesn’t. Paul’s angry behaviour is more likely to lead his wife to become unhealthily angry herself and/ or to become defensive. In Paul’s case, his anger had, in fact, both effects on his wife. Now, let’s suppose that Paul rst addressed his unhealthy anger and then discussed his dissatisfaction with his wife. His annoyance at her behaviour, but his acceptance of her as a person would help him to view her behaviour perhaps as a sign of emotional disturbance and his compassion for her would have very different effects on her. She would probably be less defensive and because Paul would not be unhealthily angry, then his wife would also be less likely to be unhealthily angry. With unhealthy anger out of the picture, the stage would be set for Paul to address the reasons for his dissatisfaction more effectively.

Disturbance before development

In the late 1960s and early 1970s I used to go to a number of encounter groups. This was the era of personal growth or development. However, there were a number of casualties of these groups and when these occurred it was because attendees were preoccupied with issues of emotional disturbance and they were being pushed too hard to go into areas of development that warranted greater resilience. In general, then, it is very diff cult for clients to develop themselves when they are emotionally disturbed. To focus on areas of development when someone is emotionally disturbed is akin to encouraging that person to climb a very steep hill with very heavy weights attached to their ankles. First, help the person to remove their ankle weights (i.e. address their emotional disturbance) before discussing the best way of climbing the hill! Downloaded by [New York University] at 06:45 14 August 2016 Dissatisfaction before development

Abraham Maslow ( 1968 ) is perhaps best known for his work on self- actualization. The relevance of this concept for our present discussion is this. It is very diff cult for humans to focus on higher order

92 DEALING WITH PROBLEMS IN ORDER

“needs” when they are preoccupied with issues with respect to lower order “needs”. Thus, if a client is faced with a general dissatisfy- ing life experience, which cannot be compartmentalized, and also wants to explore his writing ambitions, help him with the former rst unless this life dissatisfaction will help him write a better book! While I have outlined REBT’s preferred order in dealing with problems, don’t forget that it values exibility. Thus, if clients want to deal with their problems in a different order and maintain this position even after their REBT therapists have given their rationale for the disturbance-dissatisfaction-development order then their wishes should be accommodated. In all probability, their resultant experiences will testify to REBT’s position!! Downloaded by [New York University] at 06:45 14 August 2016

93 This page intentionally left blank Downloaded by [New York University] at 06:45 14 August 2016 EARLY FOCUS OF IRRATIONAL BELIEFS 20

Early focus on irrational beliefs (iBs)

Most approaches within the CBT tradition argue that cognitions occur at different levels in our cognitive system. Thus, cognitive therapists hold that automatic thoughts (often in the form of inferences) occur at the surface of our cognitive system, styles of information processing occur in the middle range of this system and cognitive schemata occur more centrally within it. In this framework, irrational beliefs can be regarded as a form of cognitive schemata in that they are beliefs rather than inferences or information processing styles. While most approaches to CBT begin at the more surface levels of the cognitive system, REBT is distinct in that it recommends that therapists encourage clients as quickly as possible to focus on the irrational, rigid and extreme beliefs that underpin their disturbed reactions, unless there are good reasons not to do so. As such, REBT adopts a hypothetico-deductive approach to assessment (DiGiuseppe, 1991a ). T he rationale for this early focus on iBs is as follows. According to REBT, theory rigid and extreme irrational beliefs are at the core of clients’ emotional problems. Therefore, if clients are to be helped to address these problems effectively they need to identify and change these irrational beliefs to their exible and non-extreme rational alternatives. This is best and most eff ciently done by a direct focus on these beliefs unless, as I said above, there are good reasons not to do this. What this means in practice is that the REBT therapist will Downloaded by [New York University] at 06:45 14 August 2016 encourage the client to select a speci c problem on which to focus. The therapist will then ask the client to select a speci c example of this problem. This speci c example will then be the focus for assessment using REBT’s ABC framework discussed earlier (see Chapter 3). During this assessment, the client will be encouraged to

95 RATIONAL EMOTIVE BEHAVIOUR THERAPY

assume temporarily that their “A” is true so that the therapist can help them to identify and work with their irrational beliefs. Other therapists in the cognitive-behavioural tradition are more likely to deal with distorted inferences (which occur at “A” in REBT’s ABC framework) or with their errors in information processing early on in therapy. Downloaded by [New York University] at 06:45 14 August 2016

96 HELPING CLIENTS TO CHANGE IRRATIONAL BELIEFS 21

Helping clients to change their irrational beliefs to rational beliefs

Perhaps the most distinctive feature about REBT practice is the efforts that REBT therapists make to help clients change their irrational (rigid and extreme) beliefs to rational ( exible and non- extreme) beliefs. This process involves a number of steps.

Helping clients to detect their irrational beliefs

T he rst step in helping clients to change their irrational beliefs to their rational alternatives is to assist them to detect their irrational beliefs. In the rst instance, this involves teaching clients about irrational beliefs and their nature. As we saw in Chapter 4 , irrational beliefs are characterized by rigidity and by being extreme. Rigid beliefs occur most frequently in the form of demands and musts and extreme beliefs, which are derived from these rigid beliefs take the form of awfulizing beliefs, discomfort intolerance beliefs and depreciation (of self, others and life conditions) beliefs. REBT therapists use a number of ways to teach clients about this vital aspect of REBT theory and help them to apply this knowledge in the assessment process to detect the irrational beliefs that underpin their emotional problems (see below).

Downloaded by [New York University] at 06:45 14 August 2016 Helping clients to discriminate their rational beliefs from their rational belief alternatives

REBT theory holds that if REBT therapists are going to help their clients overcome their problems most effectively, then they need 97 RATIONAL EMOTIVE BEHAVIOUR THERAPY

to help them to think rationally about life’s adversities rather than irrationally. As part of this process, an important task is helping clients to discriminate their irrational beliefs from their rational beliefs. In the same way that we educate our clients to understand what irrational beliefs are and the forms they take, we also teach them to understand what rational beliefs are and the forms that they take. One very important part of this process is helping clients to understand keenly the differences between irrational beliefs and rational beliefs. For example, it is not suff cient to show a client that the rational alternative to her (in this case) rigid belief, “I must impress my new boss straightaway” is the belief: “I’d like to impress my boss straightaway.” The latter may not be rigid, but neither is it not fully exible. While it asserts her preference, it does not negate her demand. The exible belief alternative to her rigid belief is: “I’d like to impress my new boss straightaway, but I do not have to do so”, which incorporates both components of the exible beliefs (see Chapter 5 ). T a ble 21.1 outlines clearly the full differences between rigid and extreme beliefs, on the one hand, and exible and non-extreme beliefs, on the other.

Disputing clients’ irrational and rational beliefs

After we have helped our clients to see the differences between their rational and irrational beliefs, REBT therapists move on to disputing these beliefs with them. This is done after clients understand the relationship between their irrational beliefs and their emotional problems and their rational beliefs and their goals. What follows applies both to clients’ speci c beliefs and their more general beliefs. As DiGiuseppe (1991 b ) has shown, disputing involves questioning

Downloaded by [New York University] at 06:45 14 August 2016 both clients’ irrational and rational beliefs to the point where they see the reasons for the irrationality of the former (i.e. they are false, illogical and lead largely to poor results) and for the rationality of the latter (i.e. they are true, logical and lead largely to good results). In addition, short didactic explanations are given until clients reach the same insight.

98 HELPING CLIENTS TO CHANGE IRRATIONAL BELIEFS

Table 21.1 Irrational and Rational Beliefs in REBT Theory Irrational Belief Rational Belief Demand Non-dogmatic preference X must (or must not happen) I would like X to happen (or not happen), but it does not have to be the way I want it to be Awfulizing belief Anti-awfulizing belief It would be terrible if X happens It would be bad, but not (or does not happen) terrible if X happens (or does not happen) Discomfort intolerance belief Discomfort tolerance belief I could not bear it if X happens (or It would be diffifi cult to bear if X does not happen) happens (or does not happen). But I could bear it and it would be worth it to me to do so Depreciation belief Acceptance belief If X happens (or does not happen) If X happens (or does not happen), I am no good/you are no good/life it does not prove that I am no is no good good/ you are no good/life is no good. Rather, I am a FHB/you are a FHB, life is a complex/mixture of good bad and neutral

FHB = Fallible human being

These questions/explanations are directed to clients’ rigid and exible beliefs as well as to their extreme and non-extreme beliefs and this is done using a variety of styles (see Chapter 22 ). In this context, a distinctive feature of REBT is its emphasis on strong disputing with certain clients at certain times in the therapeutic process, particularly when clients are demonstrating resistance (Ellis, 2002 ). This contrasts with cognitive therapy, the founder of

Downloaded by [New York University] at 06:45 14 August 2016 which has argued that cognitive therapists should not challenge their clients’ dysfunctional beliefs because to do so sounds confronta- tional. Rather they should help their clients examine, evaluate or test such beliefs, a far more gentle enterprise than disputing and certainly than strong disputing (Beck, 2002 ).

99 RATIONAL EMOTIVE BEHAVIOUR THERAPY

The use of logical arguments in disputing beliefs

In common with other CBT therapists, REBT therapists ask clients questions about the empirical status and the pragmatic status of their beliefs. However, we also ask them about the logical status of their beliefs, which other CBT therapists do less frequently and thus this is a distinctive feature of REBT. It may be that empirical and pragmatic arguments are more persuasive to clients than logical arguments. We do not know because the relevant research has not been done. Even if this is the case, in general, REBT therapists would still use logical disputing of beliefs for two reasons. First, we do not know on a priori grounds which clients will nd which arguments most persuasive in changing their irrational beliefs to the rational alternatives. Just because the majority of clients may nd logical arguments unpersuasive, it does not follow that all will do so and to withhold such arguments from those who might nd them persuasive would not be good practice. So, REBT therapists tend to use all three arguments to see, as I said above, which arguments will be most persuasive with which clients. Second, we use empirical, pragmatic and logical arguments while disputing beliefs in order to be comprehensive. This comprehensive- ness may itself be effective. Thus, even if clients nd empirical and pragmatic arguments more persuasive than logical arguments, it may still be worthwhile employing such arguments in that they may add value to the overall effectiveness of the disputing process. Some clients may nd it persuasive that their irrational beliefs are false, unhealthy and logical even if they nd the logical argument weak on its own. Downloaded by [New York University] at 06:45 14 August 2016

100 VARIETY OF THERAPEUTIC STYLES 22

Variety of therapeutic styles

Cognitive therapists are advised to adopt a therapeutic style based on the principles of collaborative empiricism (e.g. Beck, Rush, Shaw and Emery, 1979 ). This advocates therapist and client working together as equal partners in pursuit of cognitive accuracy and real- ism through the identi cation and examining of unrealistic, biased cognitions. REBT therapists would not take issue with this. How we tend to differ from other cognitive-behaviour therapists is that we are prepared to adopt a broader range of therapeutic styles than they tend to use. For example, in 1981, I spent a six-month sabbati- cal at the then Center for Cognitive Therapy in Philadelphia learning cognitive therapy. As part of our training, we had to present our work with a patient in a case conference setting and demonstrate our work with video excerpts. I presented my work with a patient with whom I had a good rapport and used humour as a way of helping her (in this case) to re-evaluate her faulty cognitions, which, in her case, was very effective. Virtually the entire case conference was devoted to a discussion of how I could have worked more according to the principles of collaborative empiricism and how I could have used non-humorous interventions to achieve similar ends. I think that this was one of the factors that led me away from cognitive therapy and re-aff rmed my commitment to REBT. REBT theory was broad enough to incorporate a number of therapeutic styles and enabled me to practise effective therapy while expressing the different sides of my personality. This was also a major reason why Downloaded by [New York University] at 06:45 14 August 2016 I did not pursue my initial training in person-centred therapy and psychodynamic therapy. My view was that both of these approaches constrained my personality so that I could not practise each mode genuinely.

101 RATIONAL EMOTIVE BEHAVIOUR THERAPY

REBT, by contrast, is not prescriptive in its advice on how REBT is practised, other than the therapist needs to be active-directive, which is the case in virtually all CBT approaches. To demonstrate REBT’s exibility with respect to therapeutic style, consider DiGiuseppe’s ( 1991b ) analysis of different styles in cognitively disputing irrational beliefs. He shows that irrational beliefs can be disputed in four styles: Socratically, didactically, metaphorically and humorously. I have added two other styles, one that I call the choice- based assessment and disputing style and the other that involves disputing irrational beliefs enactively. Let me brie y discuss the Socratic, didactic, metaphorical, humorous and enactive styles before considering the choice-based style in greater detail: • Socratic style . As discussed in C hapter 18, here, REBT therapists ask their clients open-ended questions designed to encourage them to see that their irrational beliefs are irrational and that rational beliefs are rational and the reasons why this is the case. • Didactic style . Here, REBT therapists didactically teach clients the same thing, ensuring that clients understand the didactic points being made. • Metaphorical style. Here, REBT therapists adopt a metaphorical stance and tell stories designed to illustrate the irrationality of irrational beliefs and the rationality of rational beliefs. However, unlike indirect approaches to the use of metaphor in therapy, REBT advocates that its practitioners ensure that their clients understand the points being made metaphorically. • Humorous style . Here, REBT therapists use humour to encourage clients to see how ridiculous their irrational ideas are. • Enactive style. Here, REBT therapists use action in the therapy setting to illustrate the irrationality of irrational ideas. For example, to demonstrate the irrationality of depreciating oneself on the basis of one’s action, I sometimes throw a glass of water Downloaded by [New York University] at 06:45 14 August 2016 over myself in the therapy session and ask my client whether that was a stupid thing to do (arguably yes) and am I a stupid person for acting stupidly (rationally no). It is unlikely that many cognitive therapists would use enactive techniques as an everyday part of their therapeutic armamentarium.

102 VARIETY OF THERAPEUTIC STYLES

The choice-based assessment and disputing style

S ince assessment and disputing of irrational beliefs are closely linked, I will consider them both here in this distinctive REBT educationally based style of intervention.

Using the choice-based method in assessing irrational beliefs and their healthy alternatives T he choice-based method of assessing irrational and rational beliefs involves presenting clients a choice between these two full sets of beliefs (see Chapter 4 ) when helping them to identify the set that underpinned their disturbed reaction (i.e. their irrational beliefs) while at the same time teaching them the other set (i.e. their rational beliefs) and helping them to see the more healthy consequences that stem from the latter set. It involves taking the part of the rational and irrational belief that is common to both (e.g. “I want to do well”) and then using this part to help the client discriminate between the rational belief (i.e. “I want to do well, but I don’t have to do so”) and the irrational belief (“I want to do well and therefore I have to do so”) and then to choose which belief underpinned their disturbed reaction to the adversity that they are discussing. Here is an example. Sarah came to therapy for public speaking anxiety. She chose an example when she got very anxious when giving a PowerPoint presentation at work. Assessment shows that her two main “A’s” were “My mind going blank” and “Being dismissed as an airhead by my boss”. She chose to target the former. Here is how I (WD) used the choice-based method to help her to identify her irrational belief: Downloaded by [New York University] at 06:45 14 August 2016 Windy : So we know one thing, that when you gave your presentation it was important to you that your mind would not go blank. Is that right? Sarah : Yes that’s right.

103 RATIONAL EMOTIVE BEHAVIOUR THERAPY

Windy: I’m not sure though which of two beliefs your anxiety was based on so I’d like to outline them and then you can choose between them. OK? Sarah : Fine. Windy : So when you were anxious about your mind going blank while giving the presentation was your anxiety based on Idea 1: “It is important that my mind does not go blank, but it does not follow that it must not do” or Idea 2: “It is important that my mind does not go blank and therefore it must not do so”? Sarah : Idea 2 de nitely. Windy : OK, now let’s suppose that you really believed Idea 1: “It is important that my mind does not go blank, but it does not follow that it must not do.” I know that you don’t believe this but let’s suppose that you do. What difference would this belief have made to you about your mind going blank? Sarah: Well, if I really believed it then I would not have been so nearly as scared. I still would not like going blank, but I would have dealt with it if it had happened. I think also that this belief would probably mean that I could focus more on what I was saying and thus it would have decreased the chances of my mind going blank.

Using the choice-based method in disputing irrational beliefs and their healthy alternatives T he choice-based method is also used when helping clients to question their rational and irrational beliefs. In REBT, we argue that it is important to help clients to dispute one irrational belief at a time. The choice-based method takes this one step forward and enables your client to question both their irrational beliefs and rational beliefs at the same time so that they can more easily discriminate between them on empirical, logical and pragmatic grounds and to give reasons for their Downloaded by [New York University] at 06:45 14 August 2016 choice. Let’s see how I used this method with Sarah:

Windy : So now let me help you to question both ideas. I am going to ask you to write both down and then focus on them while I ask you some questions. OK?

104 VARIETY OF THERAPEUTIC STYLES

Sarah : OK. Windy: So if you focus on both ideas, namely Idea 1: “It is important that my mind does not go blank, but it does not follow that it must not do” and Idea 2: “It is important that my mind does not go blank and therefore it must not do so”?, which idea is true and which is false? Sarah : The rst one is true and the second one is false. Windy: Why? Sarah : Well, the rst one recognizes what’s important to me but also recognizes that I don’t have to get what’s important to me. That’s how the world works. If I ran the universe then I would arrange to get what I want. That’s why the second one is false. In fact, the more I demand that I get what is important to me, in case my mind not going blank, the more chance it will happen. I then used the same method to ask Sarah which of her two beliefs was logical and which illogical and which belief was helpful and which not helpful. One last important point about therapeutic style, the late Arnold Lazarus ( 1981 ) wrote on effective therapists being like authentic chameleons. This means that therapists are prepared to, and have the interpersonal exibility to, modify, with authenticity, their therapeutic style according to the perceived needs of their clients. REBT therapists would very much agree with Lazarus on this point. Downloaded by [New York University] at 06:45 14 August 2016

105 This page intentionally left blank Downloaded by [New York University] at 06:45 14 August 2016 ENCOURAGING CLIENTS TO SEEK ADVERSITY 23

REBT encourages clients to seek adversity when carrying out homework assignments, but does so sensibly

REBT’s ABC model holds that people disturb themselves (at “C”) about adversities (at “A”) largely because they hold irrational beliefs (at “B”) about these adversities (Dryden and Neenan, 2014 ; Ellis, 1994 ). It follows, therefore, that if they want to handle these adversities more constructively, then they need to develop a set of rational beliefs about them. This suggests that, sooner or later, REBT therapists need to encourage their clients to seek out adversity in order to practise thinking rationally about this adversity. This, of course, needs to be done sensibly and I discuss below the importance of helping clients to challenge themselves without overwhelming themselves. C lients are generally ambivalent about facing adversity when carrying out homework assignments. They want to address their problems, but they would rather do this without facing adversity. This is akin to wanting to learn to swim without getting wet! Let us discuss one example where a client was happy with what he had achieved from a homework assignment, but where I, as therapist, knew that the client had not got as much out of the assignment as he thought because he had not faced adversity. Harry, the client, was anxious about speaking up in class because he was scared that his fellow students would disagree with him. As a result, he kept quiet. In our sessions, I helped him to identify and dispute the ego-based irrational beliefs that underpinned his disturbance. He saw (but did not Downloaded by [New York University] at 06:45 14 August 2016 yet believe) that it would be preferable if his fellow students agreed with him, but that they did not have to do so and he also saw that if they did, he could accept himself in face of this disagreement. We discussed the importance of putting these rational beliefs into

107 RATIONAL EMOTIVE BEHAVIOUR THERAPY

practice in the face of adversity and he agreed to speak up in class until three people had disagreed with his opinions; he would practise his newly developed rational beliefs before speaking up and after getting the disagreements. Harry came to the next therapy session in an upbeat frame of mind. I asked him to tell me how his homework assignment had gone and he said better than his wildest dreams. I was expecting him to tell me how much bene t he had got from rehearsing his rational beliefs when other students disagreed and that he would be consequently more open to voicing his opinions in class. However, he told a very different story. He said that he spoke up on a number of occasions and was surprised and delighted to learn with everyone agreed with what he had to say and some even invited him for coffee afterwards, something that had never happened before. As his therapist, I (WD) was pleased that he had spoken up, but I also knew that he had not really faced adversity (i.e. having others disagree with his views) while doing his homework assignment and thus had no real experience of thinking rationally in the face of adversity. Harry admitted that he played safe and only voiced views that he knew would be popular. As it happened, in the next week a few people did disagree with him as Harry, buoyed by false con - dence, took more risk in saying what he really thought and thus we returned to the theme of Harry helping himself by facing adversity.

REBT discourages gradualism

Another distinctive feature of REBT is its stance on the speed with which clients should ideally face adverse situations and practise thinking rationally in these situations. Many years ago, Joseph Wolpe ( 1958 ) developed a therapeutic technique, called systematic desensitization, based on the principle of reciprocal inhibition. Focusing on Downloaded by [New York University] at 06:45 14 August 2016 anxiety, Wolpe argued that the best way of dealing with anxiety was to inhibit the anxiety response to a threat by replacing that response with one that was incompatible with anxiety; namely, a relaxation response. In order to do this, Wolpe argued that the therapist had to work up very gradually a sophisticated hierarchy of graded

108 ENCOURAGING CLIENTS TO SEEK ADVERSITY

anxiety-provoking situations. In doing so, the client was to imagine each situation from a state of relaxation. At the rst sign of anxiety, the client was to stop imagining the anxiety-provoking situation and return to the relaxation state before returning to imagining the anxious scene. When the client could do this, they would then take one step up the hierarchy and repeat the procedure. Therapist and client would work very gradually up the hierarchy until the client could imagine the most anxiety-provoking scene in a state of relaxation. Ellis ( 1983b ) argued against the use of gradualism in the treatment of anxiety and other psychological disorders. He argued instead that clients should be encouraged to face their fears as implosively as they could tolerate while practising thinking rationally in such situations. His argument was threefold. First, a gradual approach to therapeutic change is not cost effective in terms of treatment sessions. It takes a very long time to help clients to work their way up hierarchies, particularly where these are complex and contain a lot of items. Second, the process does not encourage client self-reliance. The process is normally heavily dependent on the presence of the therapist, although latterly more automated desensitization programmes were developed. Third, and perhaps most crucially, a very gradual approach to the treatment of anxiety and other psychological disorders unwittingly has two main, related side-effects:

1 . F irst, gradualism reinforces clients’ philosophy of discomfort intolerance. It implicitly teaches them that they must avoid feeling anxious or must only experience low levels of anxiety. They, then, may develop anxiety about anxiety and avoid situations in which they may feel anxious. 2. Second, gradualism may wittingly encourage clients to view

Downloaded by [New York University] at 06:45 14 August 2016 themselves as fragile, too weak to cope with anything that is stressful.

REBT tends to favour full exposure in vivo where clients practise thinking rationally while facing what they truly fear. If clients do this then they can make a lot of progress quite quickly. However,

109 RATIONAL EMOTIVE BEHAVIOUR THERAPY

many clients will not do this, at least initially, and therefore REBT therapists need to encourage them to proceed according to a principle that I have called “challenging, but not overwhelming” (Dryden, 1985) rather than falling back on the gradualism principle. Using the “challenging, but not overwhelming” principle, once therapists have ascertained that their clients are not prepared to use the full exposure principle, they ask them if they are prepared to use rational thinking while facing situations that are challenging for them to face but not currently overwhelming for them. It can be seen that the “challenging, but not overwhelming” principle is a exible, pragmatic alternative to the “full exposure” and “gradualism” principles. Downloaded by [New York University] at 06:45 14 August 2016

110 USE OF THERAPIST FORCE AND ENERGY 24

Change is hard work and the use of therapist force and energy

Here is a typical exchange that I have with my clients about psychotherapeutic change:

Windy : Would you like to get over your problems quickly, at a moderate pace or slowly? Clientt : Quickly. Windy: How much effort do you want to put into therapy: a lot, a moderate amount or hardly any? Be honest now. Clientt : Well, if I’m honest, hardly any! Windy: So, let me sum up. You want to get over your problems quickly and with hardly any effort on your part. Is that correct? Clientt : Well … yes … but put like that I guess it’s unrealistic. Windy : Why do you say that? Clientt : Because saying that I can get over my problems, which I have had for a long time, quickly and without hardly any effort sounds like magic. REBT has a very realistic view of psychotherapeutic change. It argues that while clients may ideally want to get over their problems quickly and without making much effort in the process, in reality such change involves much hard work and the speed of change is related to the degree of work put in by the clients. The reasons why change does involve hard work are as follows:

Downloaded by [New York University] at 06:45 14 August 2016 • Clients often have a strong biologically based tendency to think irrationally and to hold their rigid and extreme beliefs very strongly (see Chapter 12 ). As a result, effort and force is often needed to change such strongly held beliefs.

111 RATIONAL EMOTIVE BEHAVIOUR THERAPY

• Often clients have had much practice at holding their rigid and extreme beliefs and thus they have often become “second nature” to them. • Clients often act and think in ways that are consistent with their irrational beliefs. This means that if they are going to change their irrational beliefs to rational beliefs, they need to act and think in ways that are consistent with their rational beliefs and inconsistent with their irrational beliefs. Ellis ( 2003 ) argued that for the above reasons, a distinct feature of REBT is its emphasis on a philosophy of commitment and effort. In particular, REBT encourages people to commit themselves to make themselves uncomfortable doing things that they don’t want to do so that they become comfortable later.

Force and energy in change

As I have stressed here, change involves hard work and clients need to adopt a philosophy of commitment and effort to get the most out of REBT. In so doing, they need to use techniques that involve force and energy. Thus, strong disputing of irrational beliefs is said to be more effective than weak disputing and powerfully repeating rational beliefs is deemed to be more effective than repeating them in a weak fashion. A lso, using emotive techniques (i.e. those that actively engage clients’ emotions) is preferred to techniques that are less or non- emotive. And using force and energy in behavioural change is deemed to be more helpful than being unforceful and unenergetic. The employment of shame-attacking exercises is a particularly distinctive feature of REBT. Here, clients are encouraged to act “shamefully” in public while accepting themselves unconditionally Downloaded by [New York University] at 06:45 14 August 2016 for so doing. This technique is a good example of an emotive method used with force and energy behaviourally.1 When they can, REBT therapists urge clients to integrate emotive and forceful methods with different modalities. As Ellis ( 2003 : 233) said, REBT:

112 USE OF THERAPIST FORCE AND ENERGY

Tries to use its cognitive methods with strong emotional and behavioral overtones; it uses its emotional-evocative techniques with powerful thinking and behavior; and it uses its behavioral techniques with forceful thinking and emotions.

Note

1 W hen suggesting the use of these exercises, REBT therapists ensure that a) they are relevant to client’s goals and b) that they will not have negative implications for the clients themselves or have negative impact on others present. Downloaded by [New York University] at 06:45 14 August 2016

113 This page intentionally left blank Downloaded by [New York University] at 06:45 14 August 2016 TEACHING CLIENTS GENERAL RATIONAL PHILOSOPHIES 25

Emphasis on teaching clients general rational philosophies and encouraging them to make a profound philosophic change

REBT is distinct among the cognitive-behaviour therapies in encouraging clients to work towards what we call a profound philosophic change. This means, as Ellis ( 2003 : 233) said, that REBT:

[T]ries to help them acquire several core attitudes that they can use to un-disturb themselves in a large number of situations and not merely with the emotional-behavioral problem with which they come to psychotherapy.

T he following comprises what we call a profound philosophic change in REBT: • Having and acting on strong desires, but refraining from trans- forming these desires into demands on self, others and life, no matter how strong the desires are. • Acknowledging that it is bad when desires are not met, but not awful. • Tolerating frustration and discomfort when it is in one’s interests to do so. • Unconditionally accepting oneself, warts and all, and then resolving to change aspects of self that are negative and that can be changed. This was termed USA (unconditional self-acceptance) Downloaded by [New York University] at 06:45 14 August 2016 by Ellis (e.g. 2003) – see Chapter 9 . • Unconditionally accepting others, warts and all, and then working to in uence these others for the better. This was termed UOA (unconditional other-acceptance) by Ellis (e.g. 2003) – see Chapter 9 .

115 RATIONAL EMOTIVE BEHAVIOUR THERAPY

• Unconditionally accepting life as a complex mixture of the good, the bad and the neutral and then working to change the bad and capitalize on the good. This was called ULA (unconditional life-acceptance) by Ellis (e.g. 2003)–see Chapter 9 .

Very few people can make this profound philosophic change in all areas of their life (called “superelegant” by Ellis in Weinrach, 1980 ), let alone maintain it for any length of time. A few clients may achieve such a profound change in most areas of their life and as these areas reduce the greater number of clients achieve it. Most clients tend to achieve a philosophic change in one or two areas of their life and others may make other changes that do not involve belief change (see Chapter 26 ). Both Beck (Padesky and Beck, 2003 ) and Ellis ( 2003 ) agree that REBT and cognitive therapy differ in that the former places much more emphasis on actively teaching general philosophies to clients. Apart from teaching clients the content of such general rational philosophies, REBT therapists teach their client how to change their general irrational philosophies to these general philosophies, sometimes using quite structured exercises in the process (e.g. Dryden, 2001 ). Apart from teaching their clients the content of general rational philosophies and how to acquire them cognitively, REBT therapists also teach them how best to integrate these philosophies into their overall belief system. REBT has many emotive and behavioural techniques that its therapists can call on and some REBT therapists have produced written step-by-step guidance for their use (e.g. Dryden, 2001) . Rather than dwell on these techniques here, I want to concentrate on one important point that REBT therapists teach their clients, which provides them with an organizing principle for how to get the most out of REBT’s cognitive, emotive and

Downloaded by [New York University] at 06:45 14 August 2016 behavioural techniques. This principle states that clients will get the most out of REBT and thereby increase their chances of making a profound philosophic change under the following conditions: 1. When they hold a rational belief and act and think in ways that are consistent with this belief and inconsistent with the irrational

116 TEACHING CLIENTS GENERAL RATIONAL PHILOSOPHIES

alternative to this belief. Here all psychological systems are operating together and in the service of the clients’ goals. 2 . W hen they do this in situations that are increasingly aversive either using the ooding principle or the “challenging, but not overwhelming” principle that I discussed in Chapter 23 . 3. When they repeat the above while feeling uncomfortable until they are comfortable with their new rational belief. 4. When they generalize their learning to other relevant situations. 5. When they apply the above four points in all areas of their life.

If so few clients achieve profound philosophic change, why try to help them achieve it?

When I give workshops on REBT and talk about the concept of “profound philosophic change”, I am asked the following question, when I mention that so few clients achieve a profound philosophic change: “If so few clients achieve profound philosophic change, why try to help them achieve it?” M y answer is along the following lines:

It is not possible to tell in advance how much change a client is capable of making. If I pre-judge that a client is not capable of making a profound philosophic change and therefore do not try to help them achieve it, then I am depriving them of the possibility of making such a change. Thus, I proceed on the basis that a person is capable of making a profound philosophic change until I gain evidence to the contrary. When I get that evidence, I still try to help them to make the best philosophic change they are, in fact, capable of making.

Downloaded by [New York University] at 06:45 14 August 2016 It is my view that this approach makes REBT distinctive on this issue among the cognitive-behavioural therapies.

117 This page intentionally left blank Downloaded by [New York University] at 06:45 14 August 2016 COMPROMISES IN THERAPEUTIC CHANGE 26

Compromises in therapeutic change

As discussed above, REBT encourages clients to make a “profound philosophic change” preferably across the board, but if this is not feasible, then in as many areas as possible and certainly on the problems for which they have been seeking help. The essence of such change is belief change. But what do REBT therapists do when our clients are not able or do not wish to change their beliefs from irrational (rigid and extreme) to rational ( exible and non-extreme)? T he answer lies in REBT’s basic adherence to the principle of exibility. To be more speci c, REBT therapists are prepared to make compromises with their preferred therapeutic goals (Dryden, 2013 ). So, if clients are not going to make belief-based changes, the following changes are available for therapists and clients to consider.

Inference-based change

When we focus our therapeutic efforts on our clients’ distorted inferences rather than on their irrational beliefs, we are helping them to stand back and consider the accuracy of these inferences. This very much goes against REBT’s usual strategy discussed in Chapter 20 , namely that we rst encourage our clients to assume temporarily that their inferences at “A” are true so that we can identify, challenge and change the irrational beliefs that normally underlie these distorted inferences. Downloaded by [New York University] at 06:45 14 August 2016 For example, Harriet was hurt about her best friend, Susan, not inviting her to her birthday party. Her inference at “A” was: “Susan thinks I’m boring.” The usual REBT strategy would be to encourage Harriet to assume temporarily that Susan did nd her boring and then to discover and examine her irrational beliefs about this

119 RATIONAL EMOTIVE BEHAVIOUR THERAPY

assumed “fact”. However, what if Harriet does not want to do this, is not prepared to do this, is unable to do this or is too disturbed to do this. If we work with her at the inferential level, we do the following:

• focus on her inference • assist her in collecting information that supports this inference and information that contradicts it and encourage her to write the gathered evidence under separate headings • help her to evaluate this evidence • encourage her to stand back and choose the most probable inference based on the available evidence • suggest that she test out this new inference, if relevant. Harriet was helped to do this and came to the conclusion that Susan did invite her, but the invitation probably got lost in the post. When she tested this out, she did discover that this was exactly what happened. Once clients have been helped to make an inference-based change, they are sometimes more amenable to going back and considering the possibility of making a belief-based change.

Behaviour-based change

Behaviour-based change occurs when clients do not change their irrational beliefs, but improve by effecting constructive changes in their behaviour. Such constructive change occurs under two major conditions:

1 . W hen clients replace dysfunctional behaviour with constructive behaviour. An example of this is when Fiona learned how to give effective presentations when hitherto her skills at giving

Downloaded by [New York University] at 06:45 14 August 2016 them were poor. 2. When clients acquire constructive patterns of behaviour that have previously been absent from their skill repertoire. An example of this is when Peter learned dating skills to help him with meeting and forming relationships with women.

120 COMPROMISES IN THERAPEUTIC CHANGE

In both types of situation, the constructive, behavioural changes that people make help them in two ways. First, they help to bring about more positive responses from others. For example, Fiona got better feedback from work colleagues and Peter got more dates with women. Second, they help people develop task con dence, which, in turn, can lead them to make further behavioural changes in related areas. The downside of these behaviour-based changes without con- comitant belief change is that the people concerned are still vulnerable when they face adversities. Thus, Fiona may do well as long as her presentations are well received, but can she cope with poor feedback? And Peter may do well as long as his newly acquired dating skills are also well received, but do they help him to cope with rejection from women who aren’t as impressed? The answer to these questions is probably no.

Changing the environment

Perhaps the most obvious example of this type of change is where clients remove themselves physically from the negative situational “A” in which they disturbed themselves. For example, a client who has made himself unhealthily angry about one of his co-workers’ racist attitudes, changes his job. Another common approach to changing the environment is by directly modifying it with the result that clients stop experiencing an unhealthy negative emotion. This involves clients confronting the environment in order to change it rather than avoiding it. An example of this approach is a client who makes herself unhealthily angry about her adolescent children playing music loudly on their hi- and who gets rid of her unhealthy angry feelings by taking away the hi-

Downloaded by [New York University] at 06:45 14 August 2016 system from her children so that they cannot play music loudly. As with other non-belief-based changes, making environmental changes does not help clients to also make belief-based changes since it effectively involves what we call in REBT changing the “A”. In general, changing the “A” discourages clients from changing the “B”.

121 RATIONAL EMOTIVE BEHAVIOUR THERAPY

However, getting away from an aversive environment may provide clients with an opportunity to think more clearly about how they disturbed themselves when they were in the environment and how they could have handled the situation better if they had changed their irrational belief to the alternative rational belief. This may inspire them to return to the aversive environment and practise thinking rationally in the situation. This is a good example of how changing the environment may promote later belief-based change. Downloaded by [New York University] at 06:45 14 August 2016

122 WHEN TO USE A CBF AND AN ABF 27

When to use a change-based focus (CBF) and when to use an acceptance-based focus (ABF)

One of the major recent developments within the CBT tradition has been the growth of those CBT approaches that recommend that clients mindfully accept the presence of dysfunctional cognitions and troublesome feelings without engaging with them. This may be thought of as an acceptance-based focus (ABF) and is typical of what has become known as “third-wave CBT”. REBT (which would be regarded as a “second-wave” CBT approach), on the other hand, generally recommends that clients identify, challenge and change irrational beliefs (at “B”) in the ABC framework, and respond to distorted inferences (either at “A” or at “C”). In short, REBT recommends that clients engage mindfully with troublesome cognitions (i.e. inferences and beliefs) with the purpose of changing them. This may be known as a change-based focus (CBF). While it may be thought that these two foci could not both be utilized in REBT, I believe they can. Here is how I make use of both a change-based focus (CBF), where thoughts and beliefs are targeted for change, and an acceptance-based focus (ABF), where these cognitions are mindfully accepted:

• I use a change-based focus (CBF) when encouraging clients to question their irrational beliefs in the rst instance. When clients consider that they have got enough out of this focus as they can on any particular occasion, I encourage them to shift to an

Downloaded by [New York University] at 06:45 14 August 2016 acceptance-based focus (ABF) if the irrational beliefs are still in their mind. It is unrealistic to expect a person to be convinced fully of their CBF interventions in any single disputing episode. • With highly distorted cognitive consequences of irrational beliefs, I initially teach clients to understand why these thoughts

123 RATIONAL EMOTIVE BEHAVIOUR THERAPY

are so distorted (i.e. they are the product of irrational beliefs). I then help them to use the presence of these thoughts to identify the irrational beliefs that have spawned them and then to use a change-based focus (CBF) with these iBs. I may then help them to use the same change-based focus to respond to these cognitive “C”s but to recognize that these thoughts may still reverber- ate in their mind at which point I encourage them to switch to an acceptance-based focus (ABF). Such reverberation is a natural process as the mind does not switch off from such thoughts just because CBF methods have been successfully used on any one occasion. As third-wave CBT therapists note, little productive change can be gained when clients get enmeshed and entwined with their irrational beliefs and distorted inferences and it is then when I advocate the use of an acceptance-based focus (ABF). However, from an REBT perspective, little can be gained by failing to encourage clients to respond constructively to these cognitions by employing a change-based focus (CBF) when they are able to do so.

It should be noted that this is one REBT therapist’s perspective concerning when to encourage clients to respond to problematic thoughts and beliefs and when to accept them mindfully. It is a distinctive feature that it allows such exploration of what newer CBT approaches can offer the theory and practice of REBT. Downloaded by [New York University] at 06:45 14 August 2016

124 FOCUS ON CLIENTS’ MISCONCEPTIONS 28

Focus on clients’ misconceptions, doubts, reservations, and objections to REBT

A ll CBT approaches place due emphasis on helping clients to identify and deal with a variety of obstacles to change (e.g. Dryden and Neenan, 2004a ; Leahy, 2001) . This has sometimes been referred to as “resistance”. What distinguishes REBT in this area is the emphasis it places on helping clients to identify and address their doubts, reservations and objections to the theory, concepts and practices of REBT itself (e.g. Dryden, 2001 ). In particular, a number of writers (Dryden, 2004 ; Gandy, 1985 ; Saltzberg and Elkins, 1980 ) have identi ed a number of misconceptions that clients and therapists (even other CBT therapists!) have about REBT. For example, in my client guide, I outlined the following client misconceptions (Dryden, 2004 ): 1. REBT states that events don’t cause emotional problems. This is true when negative events are mild or moderate, but not when they are very negative in nature, like being raped or losing a loved one. 2 . T he principle of emotional responsibility leads to blaming the victim. 3. If I say I disturb myself about your bad behaviour, for example, that will lead you to say that my response has got nothing to do with your behaviour. That is a cop-out and the principle of emotional responsibility promotes it. 4. The ABC model is overly simplistic.

Downloaded by [New York University] at 06:45 14 August 2016 5. REBT neglects the past. 6. The REBT concept of acceptance encourages complacency. 7. REBT neglects emotions. 8. With its emphasis on techniques, REBT neglects the therapeutic relationship.

125 RATIONAL EMOTIVE BEHAVIOUR THERAPY

9 . T he therapeutic relationship in REBT is an unequal one. 10. REBT therapists brainwash their clients. 11. REBT therapists tell their clients what to feel and what to do. 12. REBT therapists prevent clients from nding their own solu- tions to their problems. 13. REBT “straitjackets” clients. 14. REBT is only concerned with changing beliefs. 15. REBT relies heavily on verbal interchange between therapist and client. It also advocates concepts that are diff cult to grasp. This means that REBT only works with highly verbal, intel- ligent clients. I encourage REBT therapists to be mindful of the possible existence of such misconceptions that clients may have about REBT and urge them to make these explicit in the therapeutic process, before outlining ways of responding to them (Dryden, 2001 ) .

Responding to misconceptions: An example

Here is an example of how to respond to one such misconception: Misconception : REBT states that events don’t cause emotions. I can see that this is the case when negative events are mild or moderate, but don’t very negative events like being raped or losing a loved one cause disturbed emotions? Possible therapist response : Your question directly impinges on the distinction that REBT makes between healthy and unhealthy negative emotions. Let me take the example of rape that you mentioned. There is no doubt that being raped is a tragic event for both women and men. As such, it is healthy for the person who has been raped to experience a lot of distress. However, REBT Downloaded by [New York University] at 06:45 14 August 2016 conceptualizes this distress as healthy even though it is intense. Other approaches to therapy have as their goal the reduction of the intensity of negative emotions. They take this position because they do not keenly differentiate between healthy negative emotions (distress) and unhealthy negative emotions (disturbance).

126 FOCUS ON CLIENTS’ MISCONCEPTIONS

Now, REBT keenly distinguishes between healthy distress and unhealthy disturbance. Healthy distress stems from your rational beliefs about a negative activating event, while disturbance stems from your irrational beliefs about the same event. I now have to introduce you to one of the complexities of REBT theory and as I do you will see that REBT is not always as simple as ABC! REBT theory holds that the intensity of your healthy distress increases in proportion to the negativity of the event that you face and the strength of your rational beliefs. Now, when a person has been raped, her (in this case) intense distress stems from her strongly held rational beliefs about this very negative “A”. As virtually everyone who has been raped will have strongly held rational beliefs about this event, we could almost say that being raped “causes” intense healthy distress. Now let me introduce irrational beliefs into the picture. REBT theory argues that you, being human, easily transmute your rational beliefs into irrational beliefs especially when the events you encounter are very negative. However, and this is a crucial and controversial point, the speci c principle of emotional responsibility states that you are largely responsible for your emotional disturbance because you are responsible for transmuting your rational beliefs into irrational beliefs. You (and others) retain this responsibility even when you (they) encounter tragic adversities such as rape. So, REBT theory holds that when a person has been raped, she is responsible for transmuting her strongly held rational beliefs into irrational beliefs, even though it is very understandable that she should do this. Actually, if we look at the typical irrational beliefs that people have about being raped, we will see that these beliefs are not an inte- gral part of the rape experience, but re ect what people bring to the experience. Examples of irrational beliefs are:

Downloaded by [New York University] at 06:45 14 August 2016 • “I absolutely should have stopped this from happening.” • “This has completely ruined my life.” • “Being raped means that I am a worthless person.” While it is understandable that people who have been raped should think this way, this does not detract from the fact that

127 RATIONAL EMOTIVE BEHAVIOUR THERAPY

they are responsible for bringing these irrational beliefs to the experience. It is for this reason that REBT theory holds that very negative “A”s do not “cause” emotional disturbance. This is actually an optimistic position. If very negative events did cause emotional disturbance then you would have a much harder time overcoming your disturbed feelings than you do now when we make the assumption that these feelings stem largely from your irrational beliefs. One more point: Some REBT therapists dis- tinguish between disturbed emotions that are experienced when a very negative event occurs and disturbed feelings that persist well after the event has happened. These therapists would argue that being raped does “cause” disturbed feelings when the event occurs and for a short period after it has happened, but if the person’s disturbed feelings persist well after the event then the person who has been raped is responsible for the perpetuation of her disturbances via the creation and therapists argue that time-limited irrationalities in response to very negative activating events are not unhealthy reactions, but the perpetuation of these irrationalities is unhealthy. Thus, for these REBT therapists a very negative event like rape does “cause” emotional disturbance in the short term, but not in the long term. P lease note that while I have presented this response as if the therapist is lecturing the client, in practice, he or she would fully engage the client in a discussion of the relevant issues. The above presentation is constrained by the book’s format, which limits the publication of very lengthy therapist-client dialogue. I have provided suggestions for how to respond to all the misconceptions listed above elsewhere (see Dryden, 2004 ).

Downloaded by [New York University] at 06:45 14 August 2016 Doubts, reservations and objections to particular aspects of REBT theory and practice

A part from these misconceptions, REBT therapists are also on the lookout for the possible presence of a number of clients’ doubts,

128 FOCUS ON CLIENTS’ MISCONCEPTIONS

reservations and objections to particular aspects of REBT theory and practice. When they are found they are explicitly discussed and dealt with, thus freeing clients to get the most out of REBT. Here are some common doubts, reservations and objections:

1. Doubts, reservations and objections to adopting rational beliefs (i.e. exible beliefs, non-awfulizing beliefs, discomfort tolerance beliefs and/or acceptance beliefs) and to giving up irrational beliefs (i.e. rigid beliefs, awfulizing beliefs, discomfort intolerance beliefs and/or depreciation beliefs). 2. Doubts, reservations and objections to adopting healthy negative emotions and to giving up unhealthy negative emotions. 3. Doubts, reservations and objections to adopting constructive behaviour and to giving up unconstructive behaviour. See Dryden ( 2001 ) for examples of how to deal with such doubts, reservations and objections. Downloaded by [New York University] at 06:45 14 August 2016

129 This page intentionally left blank Downloaded by [New York University] at 06:45 14 August 2016 THERAPEUTIC EFFICIENCY 29

Therapeutic effifi ciency

Albert Ellis was always interested in eff ciency both in life and in psychotherapy. A distinctive feature of REBT, therefore, is the emphasis that it places on eff ciency in its practice. In a seminal paper, Ellis ( 1980c ) speci ed several criteria of psychotherapeutic eff ciency. None of these criteria on its own de nes REBT’s distinctive contribution. This is de ned by all seven taken together.

Brevity

REBT therapists aim to help clients in the shortest time possible. This is why we endeavour to teach clients to use the skills of REBT to help themselves. We do this to save therapists time and clients money. However, we also realize that some clients who are really quite disturbed cannot be helped brie y. As a practical example of brevity in REBT, Albert Ellis for many years ran his “Friday Night Workshops”1 at the Albert Ellis Institute. At these events, Ellis conducted live therapy with audience volunteers on their problems in living and then both Ellis and the volunteer would take questions from the audience. Research undertaken by Ellis and Joffe ( 2002 ) showed that volunteers often received much help from just one short session. Thus, REBT is an excellent example of CBT-oriented single session therapy. Downloaded by [New York University] at 06:45 14 August 2016 Depth-centredness

One of REBT’s distinctive features is its early focus on irrational beliefs (see C hapter 20) . It argues that irrational (i.e. rigid and extreme) beliefs are at the core of psychological disturbance and

131 RATIONAL EMOTIVE BEHAVIOUR THERAPY

therefore clients can be helped as quickly as possible to identify, challenge and change these beliefs and develop and practise rational alternatives to these beliefs.

Pervasiveness

Pervasiveness in psychotherapy is de ned as “the therapists helping the clients to deal with many of their problems, and in a sense their whole lives, rather than with a few presenting symptoms” (Ellis, 1980c : 415). While other CBT therapies recognize that a client’s problems are underpinned by a number of core beliefs (known as core irrational beliefs in REBT), REBT not only endeavours to help clients to zero in and change their core irrational beliefs as soon as is feasible it endeavours to teach clients a rational self-helping philosophy that they can apply across the board.

Extensiveness

As Ellis ( 1980c ) noted, extensiveness means helping clients not only to minimize their disturbed feelings, but also to promote their potential for happy living. REBT is best placed to do this among the CBT therapies as it has been used extensively both in clinical and personal development settings.

Thoroughgoingness

REBT uses a plethora of cognitive, emotive and behavioural techniques in a thoroughgoing manner. It may not be as comprehensive as multimodal therapy (Lazarus, 1981 ), but it runs it close. Downloaded by [New York University] at 06:45 14 August 2016

Maintaining therapeutic progress

REBT argues that once clients have made progress in therapy they have to work hard to maintain this progress. In particular, REBT is

132 THERAPEUTIC EFFICIENCY

fairly unique among the CBT therapies in highlighting the philosophy of discomfort intolerance in being a prime obstacle to therapeutic progress (Ellis, 2002 ). REBT focuses clients on this philosophy and encourages them to develop a philosophy of high frustration tolerance to help them to maintain and even enhance their therapeutic progress.

Promotion of prevention

An effcient psychotherapy not only helps clients to deal with the emotional problems that they have, it also helps them to prevent the development of future problems. REBT does this by: • Teaching clients to identify their vulnerabilities and the themes that de ne them (e.g. failure, being rejected, etc.). • Helping them to identify, challenge and change the irrational beliefs that underpin these vulnerabilities. • Encouraging them to develop constructive behaviours and realistic modes of thinking that they can implement as a way of reinforcing their developing rational beliefs. • Suggesting that they practise healthy ways of thinking and acting before they enter and while they are facing situations in which they are liable to disturb themselves. • Urging them to seek out increasingly diff cult situations to con- front in which they would normally disturb themselves, but instead rehearse healthy beliefs and act and think in ways that are constructive and realistic .

Note Downloaded by [New York University] at 06:45 14 August 2016 1 T hese events are still run at the Albert Ellis Institute and are known as “Friday Night Live”.

133 This page intentionally left blank Downloaded by [New York University] at 06:45 14 August 2016 THEORETICALLY CONSISTENT ECLECTICISM 30

Theoretically consistent eclecticism

REBT is a form of what I have called theoretically consistent eclecticism (Dryden, 1986) . This means that REBT therapists are encouraged to draw broadly from a variety of therapeutic approaches but in ways that are consistent with REBT theory. Don’t forget that, in this book, I am particularly discussing the speci c form of REBT – rather than its general form which is, as Ellis ( 1980a ) argued, indistinguish- able from CBT. When practising general REBT, REBT therapists will draw liberally from other approaches, particularly other CBT approaches and when we do so, we are less concerned about the consistency of what we borrow with REBT theory. In all probability, different REBT therapists take different things from different approaches and as such there are different “ avours” of theoretically consistent eclectic therapy. To demonstrate this, let me brie y outline what I routinely borrow from other approaches.

Windy Dryden’s brand of eclectic REBT

In this section, I will brie y discuss the following: working alliance therapy, cognitive therapy, experiential approaches and the practice of mindfulness.

Working alliance theory Downloaded by [New York University] at 06:45 14 August 2016 Bordin (1979 ) has been credited with being the pioneer of this framework. He argued that the alliance between clients and therapists has a number of components:

135 RATIONAL EMOTIVE BEHAVIOUR THERAPY

1. bonds (the interpersonal connectedness between clients and therapists) 2. goals (what clients want to achieve from therapy and what their therapists want them to achieve) 3. tasks (what clients and therapists do to help clients to achieve their goals).

Bordin ( 1979 ) has argued that effective therapy is more likely to occur when the bonds between clients and therapists are strong and enable both to work together, when clients and therapists agree with the goals of therapy and when both are willing and able to carry out the tasks that are potent enough to help clients to achieve their goals. I use this framework to guide my general strategies and speci c technique. I have also suggested a fourth component, which I call “views”, that focuses on the ideas both clients and therapists have about what determines the clients’ problems, how these can best be ameliorated and other salient aspects of the therapeutic endeavour (Dryden, 2011 ). Here, effective therapy is more likely to occur when clients and therapists have similar views about therapy.

Cognitive therapy I particularly nd the concepts of agenda setting and developing a problem list that originated in cognitive therapy (Beck et al., 1979 ) helpful, especially with clients who are cognitively and emotionally disorganized and those who jump from problem to problem and topic to topic. Such procedures provide greater structure to REBT and it is interesting to see that both Beck (Padesky and Beck, 2003) and Ellis ( 2003 ) agree that the routine practice of cognitive therapy is more structured than the routine practice of REBT.

Downloaded by [New York University] at 06:45 14 August 2016 Experiential approaches I employ techniques from experiential approaches to therapy such as gestalt therapy mainly to help clients to identify feelings and thoughts that are diff cult to identify employing usual assessment methods. Focusing methods (Gendlin, 1978 ) are particularly useful

136 THEORETICALLY CONSISTENT ECLECTICISM

in identifying feelings and two-chair methods from gestalt therapy (Passons, 1975 ) are useful in helping to identify thoughts because they are required to articulate them during the technique. I should add that, consistent with REBT theory, I do not think that such methods are therapeutic in themselves, but in the assistance that they provide in helping me practise speci c REBT when usual methods fail.

Mindfulness The use of mindfulness practice (Kabat-Zinn, 1990 ) is increasing in CBT, initially in the treatment of recurrent depression (Segal, Williams and Teasdale, 2012 ) and latterly in other disorders. The purpose of this approach to meditation is to help clients not to engage with harmful thoughts but to let them pass through their mind. As discussed more fully in Chapter 27 , I use such methods after I have encouraged clients to dispute their irrational beliefs and when they are still holding distorted inferences at “C” in the ABC framework that persist even when these inferences have been questioned.

Techniques that are avoided in REBT

So far, I have discussed the use of techniques within the theoretically consistent eclectic practice of REBT. It is also useful to consider what techniques are not employed in REBT even within its eclectic practice (Dryden and Neenan, 2004b ): 1 . T e c hniques that help people become more dependent, e.g. undue therapist warmth as a strong reinforcement and the creation and analysis of a transference neurosis. 2. Techniques that encourage people to become more gullible and Downloaded by [New York University] at 06:45 14 August 2016 suggestible, e.g. Pollyannaish positive thinking. 3. Techniques that are long winded and ineff cient, e.g. psychoanalytic methods in general and free association in particular; encouraging clients to give lengthy descriptions of activating experiences at “A”.

137 RATIONAL EMOTIVE BEHAVIOUR THERAPY

4. Methods that help people feel better in the short term rather than get better in the long term (Ellis, 1972 ), e.g. some experiential techniques such as fully expressing one’s feelings in a dramatic, cathartic and abreactive manner, i.e. some gestalt methods and primal techniques. The danger here is that such methods may encourage people to practise irrational philosophies underlying such emotions as anger. 5. Techniques that distract clients from working on their irrational philosophies, e.g. relaxation methods, yoga and other cognitive distraction methods. These methods may be employed, however, along with cognitive disputing designed to yield some philosophic change. 6. Methods that may unwittingly reinforce clients’ philosophy of discomfort intolerance, e.g. gradual desensitization (see Chapter 23 ). 7. Techniques that include an anti-scienti c philosophy, e.g. faith healing and mysticism. 8 . T e c hniques that attempt to change activating events (“A”) before or without showing clients how to change their irrational beliefs (“B”), e.g. some strategic family systems techniques. 9 . T e c hniques that have dubious validity, e.g. neurolinguistic programming. Having said this, it is important to note that REBT therapists do not avoid using the above methods in any absolute sense. We may, on certain restricted occasions with certain clients, utilize such techniques, particularly for pragmatic purposes. For example, if faith healing is the only method that will prevent some clients from harm- ing themselves, then we might either employ it ourselves or, more probably, refer such clients to a faith healer (Ellis, 2002 ). This shows the relativistic core of REBT, which is perhaps its most distinctive

Downloaded by [New York University] at 06:45 14 August 2016 feature!

138 References

Barzun , J. ( 1964 ). Of Human Freedom . Philadelphia : Lippincott . Beck , A.T. ( 1976 ). Cognitive Therapy and the Emotional Disorders . New York : International Universities Press . B e c k , A.T. (2002, June 4 ). T he word “Challenge” . Academy of Cognitive Therapy Listserve Posting . B e c k , A.T. , Rush , A.J. , Shaw , B.F. and Emery , G. ( 1979 ). Cognitive Therapy of Depression . New York : Guilford Press . B o r din , E.S. ( 1979 ). T he generalizability of the psychoanalytic concept of the working alliance . Psychotherapy: Theory Research and Practice , 16 : 252 – 260. DiGiuseppe , R. ( 1991a ). A rational-emotive model of Assessment . In M. Bernard (Ed.), U sing Rational-Emotive Therapy Effectively . New York : Plenum Press . DiGiuseppe , R. ( 1991b ). Comprehensive cognitive disputing in rational- emotive therapy . In M. Bernard (Ed.), Using Rational-Emotive Therapy Effectively . New York : Plenum Press . Dobson , K.S. (Ed.) ( 2001 ). Handbook of Cognitive-Behavioral Therapies , Downloaded by [New York University] at 06:45 14 August 2016 2nd edn . New York : Guilford Press . D r y den , W. ( 1985 ). Challenging but not overwhelming: a compromise in negotiating homework assignments. British Journal of Cognitive Psychotherapy , 3 ( 1 ), 77 – 80 .

139 REFERENCES

D r yden, W. (1986 ). A case of theoretically consistent eclecticism: humanizing a computer addict. International Journal of Eclectic Psychotherapy , 5( 4 ), 309 – 327 . D r yden , W. (Ed.) ( 1989 ). Howard Young – Rational Therapist: Semi- nal Papers in Rational-Emotive Therapy . Loughton : Gale Centre Publications . D r y den , W. ( 1997 ). Therapists’ Dilemmas , rev. edn . London : Sage . D r yden , W. ( 1998 ). Understanding persons in the context of their problems: a rational emotive behaviour therapy perspective. In M. Bruch and F.W. Bond (Eds.), Beyond Diagnosis: Case Formulation Approaches in CBT. Chichester : Wiley . Dryden , W. ( 1999 ). Beyond LFT and discomfort disturbance: the case for the term non-ego disturbance . Journal of Rational-Emotive and Cogni- tive-Behavior Therapy , 17 ( 3 ), 165 – 200 . Dryden , W. ( 2001 ). Reason to Change: A Rational Emotive Behaviour Therapy REBT Workbookk . Hove : Brunner-Routledge . Dryden , W. ( 2004 ). Rational Emotive Behaviour Therapy: Clients’ Manuall. London: Whurr . D r y den , W. ( 2009 ). Understanding Emotional Problems: The REBT Per- spective . Hove : Routledge . D r y den , W. ( 2011) . Counselling in a Nutshelll , 2nd edn . London : Sage . D r y den , W. ( 2013 ). Comprom ises in rational-emotive therapy . In W. Dryden , Rationality and Pluralism. Selected Writings of Windy Dryden . Hove : Routledge . D r y den , W. , Gordon , J. and Neenan , M. ( 1997 ). Wh at is Rational Emotive Behaviour Therapy A Personal and Practical Guide . Loughton : Gale Centre Publications . D r y den , W. and Neenan , M. ( 2004a ). The Rational Emotive Behavioural Approach to Therapeutic Change . London : Sage . D r y den , W. and Neenan , M. ( 2004b ). Counselling Individuals: A Rational Emotive Behavioural Handbookk . London : Whurr .

Downloaded by [New York University] at 06:45 14 August 2016 Dryden , W. and Neenan , M. ( 2014 ). Rational Emotive Behaviour Therapy: 100 Key Points and Techniques , 2nd edn . Hove : Routledge . E llis , A. ( 1962 ). Reason and Emotion in Psychotherapy . Secaucus, NJ : Lyle Stuart . Ellis , A. ( 1972 ). Helping people get better: rather than merely feel better . Rational Livingg, 7 ( 2 ), 2 – 9 . 140 REFERENCES

Ellis , A. ( 1976 ). The biological basis of human irrationality . Journal of Individual Psychology , 32 , 145 – 168 . Ellis , A. ( 1978 ). Toward a theory of personality . In R.J. Corsini (Ed.), Read- ings in Current Personality Theories . Itasca, IL : Peacock . E llis , A. ( 1979 ). D iscomfort anxiety: a new cognitive behavioral construct. Part 1 . Rational Livingg, 14 ( 2 ), 3 – 8 . E llis , A. ( 1980a ). Rat ional-emotive therapy and cognitive behavior therapy: similarities and differences . C ognitive Therapy and Research , 4 , 325 – 340 . E llis , A. ( 1980b ). D iscomfort anxiety: a new cognitive behavioral construct. Part 2 . Rational Livingg, 15 ( 1 ), 25 – 30 . Ellis , A. ( 1980c ). The value of eff ciency in psychotherapy . Psychotherapy: Theory Research and Practice , 17 , 414 – 418 . E llis , A. ( 1983a ). T he case against religiosity . New York : Albert Ellis Institute . E llis , A. ( 1983b ). The philosophic implications and dangers of some popular behavior therapy techniques . In M. Rosenbaum , C.M. Franks and Y. Jaffe (Eds.), Perspectives in Behavior Therapy in the Eighties . New York : Springer . E llis , A. ( 1987 ). T he use of rational humorous songs in psychotherapy . I n W . F . F r y, Jr. and W.A. Salameh (Eds.), Handbook of Humor in Psychotherapy: Advances in the Clinical Use of Humorr. Sarasota , FL: Professional Resource Exchange, Inc . Ellis , A. ( 1994 ). Reason and Emotion in Psychotherapy , rev. updated edn . N ew York: Birch Lane Press . E llis , A. ( 2002 ). Overcoming Resistance: A Rational Emotive Behavior Therapy Integrated Approach , 2nd edn . New York : Springer . E llis , A. ( 2003 ). S imilarities and differences between rational emotive behavior therapy and cognitive therapy . Journal of Cognitive Psycho- therapy: An International Quarterly , 17 , 225 – 240 . Ellis , A. ( 2004 ). Rational Emotive Behaviour Therapy: It Works For Me – It

Downloaded by [New York University] at 06:45 14 August 2016 Can Work For You . New York : Prometheus Books . Ellis , A. and Dryden , W. ( 1997 ). The Practice of Rational Emotive Behavior Therapy, 2nd edn . New York : Springer . E llis , A. and Joffe , D. ( 2002 ). A study of volunteer clients who experience live sessions of REBT in front of a public audience. Journal of Rational Emotive and Cognitive Behavior Therapy , 20 ( 2 ), 151 – 158 . 141 REFERENCES

Freud , A. ( 1937 ). The Ego and the Mechanisms of Defence . L ondon : Hogarth . G a n dy , G.L. ( 1985 ). Frequent misperceptions of rational-emotive therapy: an overview for the rehabilitation counselor . Journal of Applied Rehabilitation Counselingg, 16 ( 4 ), 31 – 35 . Gendlin , E.T. ( 1978 ). Focusingg . New York : Everest House . Grieger , R.M. and Boyd , J. ( 1980 ). Rational-Emotive Therapy: A Skills- based Approach . New York : V an Nostrand Reinhold . Hjelle , L.A. and Ziegler , D.J. ( 1992 ). Personality Theories: Basic Assump- tions Research and Applications . New York : McGraw-Hill . Kabat-Zinn , J. ( 1990 ). Full Catastrophe Living: Using the Wisdom of Your Mind and Your Body to Face Stress Pain and Illness . New York : Dell Publishing . Korzybski , A. ( 1933 ). Science and Society . San Francisco : ISGS . Lazarus , A.A. ( 1981 ). The Practice of Multimodal Therapy. N ew York : McGraw-Hill . L e a hy , R.L. ( 2001 ). Overcoming Resistance in Cognitive Therapy . N ew York : Guilford Press . M a s low , A. ( 1968 ). Toward a Psychology of Beingg. New York : Van Nostrand Reinhold . P a desky , C.A. and Beck , A.T. ( 2003 ). Science and philosophy: Comparison of cognitive therapy and rational emotive behavior therapy . Journal of Cognitive Psychotherapy: An International Quarterly , 17 , 211 – 224 . Passons , W.R. ( 1975 ). Gestalt Approaches in Counselingg. New York : Holt Rinehart & Winston . Persons , J. ( 1989 ). Cognitive Therapy: A Case Formulation Approach . New York : Norton . R e ivich , K. and S hatte , A. ( 2002 ). The Resilience Factor: 7 Keys to Finding your Inner Strength and Overcoming Life’s Hurdles . New York : Broad- way Books . Rogers , C.R. ( 1957 ). The necessary and suff cient conditions of therapeutic

Downloaded by [New York University] at 06:45 14 August 2016 personality change . Journal of Consulting Psychology , 21 , 95 – 103 . S a ltzberg , L. and E lkins , G.R. ( 1980 ). An examination of common concerns about rational-emotive therapy . Professional Psychology: Research and Practice , 1 1( 2 ), 324 – 330 . Segal , Z.V. , Williams , J.M.G. and Teasdale , J.D. ( 2012 ). Mindfulness-based Cognitive Therapy for Depression , 2nd edn . New York : Guilford Press . 142 REFERENCES

Walen , S.R. , DiGiuseppe , R. and Wessler , R.L. ( 1980 ). A Practitioner’s Guide to Rational-Emotive Therapy . New York : Oxford University Press . Weinrach , S.G. ( 1980 ). Unconventional therapist: Albert Ellis . Personnel and Guidance Journall , 59 , 152 – 160 . W e s s ler , R.A. and Wessler , R.L. ( 1980 ). The Principles and Practice of Rational-Emotive Therapy . San Francisco : Jossey-Bass . Wolpe , J. ( 1958 ). Psychotherapy by Reciprocal Inhibition . Stanford, CA : Stanford University Press . Young , J.E. and Klosko , J.S. ( 1993 ). Reinventing Your Life: The Break- through Program to End Negative Behavior and Feel Great Again . N ew York : Plume . Z i e gler, D.J. (2000 ). Basic assumptions concerning human nature underlying rational emotive behaviour therapy (REBT) personality Theory . Journal of Rational-Emotive and Cognitive-Behavior Therapy , 18 , 67 – 85 . Downloaded by [New York University] at 06:45 14 August 2016

143 This page intentionally left blank Downloaded by [New York University] at 06:45 14 August 2016 Index

Note : Page numbers in italic refer to gures, those in bo ld to tables. 3 × 2 disturbance matrix 49–51, 50 assertion of acceptance component 3 × 2 health matrix 51–3, 52 29–30 assessment: choice-based method ABC model 15–16, 83, 95–6, 107 in 103–4; hypothetico-deductive a bsolute truth 3 approach to 95 a bsolutism 17 awfulizing, negated 25–6 acceptance: assertion of 29–30; by therapists 79–80; of humans 42; badness, asserted 25 unconditional 71, 79–80 Barzun, J. 4 acceptance-based focus (ABF) 123–4 Beck, A.T. 4, 15, 99, 116, 136 accounts, accuracy of 3 behaviour 9; change based on action tendencies, inferences 120–1; inferences about 59 about 59 behavioural responsibility, and adversity: responses to 8; seeking emotional responsibility 37–8 107–10 beliefs: acceptance 28–30; awfuliz- a n ger, unhealthy 91–2 ing 19; changing irrational to anti-extremism 73–4 rational 97–100, 103–4; clients’ anxiety 108–9; choice-based treat- 35, 111–12; core irrational 132;

Downloaded by [New York University] at 06:45 14 August 2016 ment of 103–4 depreciation 20–1; detection of approval, by therapists 79 97; discomfort intolerance 19–20; asserted badness component 25 discomfort tolerance 26–8; dis- asserted preference 23 crimination of 97–8; disputation asserted struggle component 26–7 of 98–100; extreme 4, 19, 64–5;

145 INDEX

exible 23–4, 51–3, 64–5; inabil- 135; and GMH 73; humour in 81; ity to change 72; irrational (iBs) mindfulness in 137; obstacles to 12, 15, 17–21, 31, 71, 88, 95–100, change in 125; therapists 100, 127; non-awfulizing 24–6; non- 102, 124–5; “third-wave” 123; extreme 24–30, 64–5; rational 15, unconditional respect in 80 23–31, 71, 88, 97–100; rigid 4, c o llaborative empiricism 101 12–13, 17–18, 49–51, 64–5, 95; commitment, to meaningful vs. interpretations 3 pursuits 75 blame , and emotional responsibility conditional human worth 41–2 36–7 consequences 15; cognitive 39 b onds 136 constitutionalism 6 –7 Bordin, E.S. 135–6 constructivism, and REBT 11 brevity, of REBT 131 cop-out criticism 38

case conceptualization 83 delight 33 case formulation 83–5 demandingness 17 case studies 111; Fiona 120–1; depreciation, negation of 29 Harriet 119–20; Harry 107–8; d e pth-centeredness, of REBT 131–2 misconception 126–8; Peter des ires: and exible beliefs 64–5; 120–1; Sarah 103–5 and rigid beliefs 17, 64–5; “ c hallenging, but not overwhelming” short-term 10 principle 110, 117 d eterminism 6 –7 change, obstacles to 125 development problems, dealing change-based focus (CBF) 123–4 with 91–3 changeability 6 –7 D iGiuseppe, R. 102 choice, in psychological change 72 di scomfort 49; anxiety 45; distur- clients: beliefs of 35, 97–100; dis- bance 45–53; tolerance 47–8 torted inferences of 39; doubts, di sputing 98–100; choice-based reservations and objections of method in 104–5 128–9; emphasis on learning by di ssatisfaction, dealing with 91–3 90; misconceptions of 125–8; di stinctiveness 5–13 teaching rational philosophies to di sturbance: dealing with 91–3; 115–17; teaching in REBT 87–9; discomfort 45–53; ego 45–53; and therapeutic change 71 and health 45–53; and health cognition, and human disturbance 8 matrices 49–53; meta-emotional cognitive therapy 136 55; meta-psychological 55–62; cognitive-behaviour therapy (CBT) origins of 69; perpetuation of

Downloaded by [New York University] at 06:45 14 August 2016 ix–x, 11, 135; ABC assessment in 69–70; psychological 17–21; 15, 83; ABF in 123; and accept- teaching about 88 ance 48; and anxiety 32; case disturbed reactions: inferences about formulation in 83; and cognition 57–62; no inferences about 55–7 95; and core beliefs 132; and dis- d o gmatism 17 turbance 55; and general REBT doubts, about REBT 128–9

146 INDEX

D r yden, W.: 3 × 2 health matrices of emotional problems, dealing with 49, 50 , 51, 52; on achieving pro- 91–3 found philosophic change 117; emotional responsibility 35–8; and and case formulation 84; “chal- behavioural responsibility 37–8; lenging, but not overwhelming” and blame 36–7 principle of 110, 117; client emotions: negative 8, 31–3, 88; misconceptions list 125–6, 128; positive 33 on disturbance 45, 55; on doubts, empathy 71, 79 reservations and objections 129; energy and force in change 112–13 eclectic REBT brand of 135–7; environment: change of 121–2; on emotive and behaviour tech- mindfulness of 10 niques 116; psycho-educational environmentalism 6 –7 emphasis of 87–90; response to E p ictetus 8, 17 misconceptions by 126–8; on e t hical humanism 11 UNEs and HNEs in REBT 31– 2 ; “evaluation” component 29 UPCP approach of 84–5; use of e x istential humanism, and REBT 11 CBF and ABF by 123–4; use of e x periential approaches 136–7 compromise by 119 extensiveness, in REBT 132

eclecticism, theoretically consistent exibility 73–4, 119 135–8 ooding principle 117 e f ciency, therapeutic 131–3 focusing methods 136–7 e go 49; anxiety 45; disturbance force and energy in change 112–13 45–53; health 46–7, 51–3 freedom 6 –7 elementalism 6 –7 general semantics theory (GST) Ellis, A.: against gradualism 109; on 12–13 biological tendencies 63; and case genuineness 71, 79 formulation 84; and constructiv- gestalt therapy 136–7 ism 11; de nition of ULA, UOA goals 136; long-term 10 and USA by 48, 115–16; disaffec- good mental health (GMH) 73–6, 89 tion with psychoanalysis 10–11; Gordon, J., health matrices 49, 51 on forms of disturbance 45; on gradualism, discouragement of forms of REBT 16; “Friday 108–10 Night Workshops” of 131, 133n; on philosophy of commitment h ealth, and disturbance 45–53 112; and profound philosophic health matrices, and disturbance change 115; psycho-educational 49–53

Downloaded by [New York University] at 06:45 14 August 2016 emphasis of 87–90; and religios- healthy negative emotions (HNEs) ity 13; and responsible hedonism 31–3, 126–8 9–10; speci cation of therapeutic healthy positive emotions (HPEs) 33 eff ciency by 131–3; on therapist hedonism: long-term 47, 76; warmth 79 responsible 9–10 emotional insight 88 heterostasis 6 –7

147 INDEX

holism 6 –7 mania 33 homeostasis 6 –7 Maslow, A. 92 homework assignments, seeking mental health, good (GMH) 73–6 adversity in 107–10 m eta-emotional disturbance 55 h uman disturbance, and cognition 8 meta-psychological disturbance human irrationality: biological 55–62 basis of 63–7; teaching of 65–6; mindfulness 137 ubiquity of 63–4 misconceptions: by clients 125–8; human nature: basic assumptions of responding to 126–8 6 –7; REBT position on 5–13 m u ltimodal therapy 132 human rationality, teaching of 65–6 human worth, and REBT 41–3 Neenan, M., health matrices 49, 51 humans, unconditional acceptance n e gated awfulizing component 25–6 of 42 n e gated demand 23 humour, in REBT 81 n e gated unbearability component 27 inferences 15, 17–18; change based negation of depreciation on 119–20; common 59; highly component 29 distorted 39 n e gative emotions 8, 31–3 informality, in REBT 80 Nielsen, S. 12 i nsight, intellectual and emotional 88 non-ego disturbance 45 interactionism 9 non-Utopian outlook 74 internalization , of rational beliefs 71 interpretations: testing of 4; vs. o bjections, to REBT 128–9 beliefs 3 o bjectivity 6 –7 irrational beliefs see beliefs, o t her-acceptance, unconditional irrational (iBs) (UOA) 48, 115 irrationality 6 –7; human 63–7; o t her-depreciation (OD) 48 irrational replacement of 66–7 o t her(s) 49; exible beliefs about 52–3; rigid beliefs about 50 k nowability 6 –7 outlook, non-Utopian 74

language: A–C and B–C 35–6; p arity, in therapy 80 imprecise 12; irrational 12 p ersonal responsibility 73 Lazarus, A. 105 p ersonality theories 5; underlying learning, emphasis on 90 assumptions of 6 –7 li fe 49 Persons, J. 83

Downloaded by [New York University] at 06:45 14 August 2016 li fe conditions: exible beliefs p ervasiveness, in REBT 132 about 53; rigid beliefs about 51 p henomenology, emphasis of 7–8 li fe-acceptance, unconditional p ositive regard 79 (ULA) 48, 116 p ost-modern relativism 3–4 life-depreciation (LD) 48 p references 18; non-dogmatic 23, loss, responses to 8 25–6, 28

148 INDEX

prevention, promotion of 133 existential-humanistic emphasis p r izing 79 of 11; experiential approaches proactivity 6 –7 to 8, 136–7; extensiveness in probabilistic approach 4 132; general 16; getting the most p roblems: about problems 55; order out of 116–17; and good mental of dealing with 91–3; perpetu- health (GMH) 73–6; and human ation of 89; psychological 71; worth 41–3; humour in 81, 102; teaching clients about 88 informality of 80; irrational and profound philosophic change rational beliefs in 9 9 ; mainte- 115–17 nance of progress in 132–3; psycho-educational approach 87–90 metaphorical style in 102; psychodynamism, of REBT 10–11 misconceptions about 125–8; psychological change: choice in 72; pervasiveness in 132; philosophy and REBT 71–2 of 112; position on human nature psychological disturbance, and 5–13; profound philosophic irrational beliefs 17–21 change in 115–17; promotion p s ychological health, and rational of prevention by 133; psycho- beliefs 23–30 educational approach in 87–90; p s ychological interactionism 9 psychodynamism of 10–11; and p s ychological problems, origin and psychological change 71–2; and maintenance of 69–70 psychological problems 69–70; p s ychotherapy, systems approaches and religiosity 13; seeking adver- to 13 sity in 107–10; self-relativism of 4; semantics emphasis of 12–13; rape: and blame 36–7; and shame-attacking exercises unhealthy distress 126–8 in 112; Socratic style in 102; rational beliefs see beliefs, rational speci c 16; systemic emphasis rational emotive behaviour therapy of 13; techniques avoided in (REBT): ABC model of 15–16, 137–8; therapeutic relationship 83, 95–6, 107; assumptions on in 79–81; thoroughgoingness in human nature 5–7; basis of 3; 132; UNEs and HNEs in 31–3 behavioural emphasis of 9; rational therapy 8 brevity in 131; case formulation rational-emotive therapy (RET) 8–9 in 83–5; change-based methods rationality 6 –7, 72; human 63; 90; choice in 72; choice-based lapses in 66–7 style in 103–5; constructivistic reactions, disturbed at A and C 55–7 emphasis of 11; debth-centered- reactivity 6 –7

Downloaded by [New York University] at 06:45 14 August 2016 ness of 131–2; didactic style in reality 3, 18 102; discouragement of gradual- reciprocal inhibition 108 ism in 108–10; doubts, reserva- relativism 138; post-modern 3–4 tions and objections to 128–9; religiosity 17; and REBT 13 and emotional responsibility reservations, about REBT 128–9 35–8; enactive style in 102; resistance 125

149 INDEX

respect 79 102, 124–5; changing beliefs by responsible hedonism 9–10 97–100, 119; and client accounts rigidities see beliefs, rigid 3–4; client expectations of 87; risk taking, calculated 76 and core facilitative conditions R o gers, C. 79 71; early focus of 95–6; eclecticism of 135–8; eff ciency of s c hema-focused therapy 39 131–3; and emotional responsi- scie nti c thinking 74 bility 35; feedback elicitation by self 49; exible beliefs about 51–2; 90; force and energy of 111–13; rigid beliefs about 49–50 and homework assignments self-acceptance, unconditional 107–8; and human nature 5, 11; (USA) 48, 115 informality of 80; misconceptions self-actualization 92 of 125; novice 39; REBT 3–4, 32, self-depreciation (SD) 45, 48 113n, 116, 125–6; and religios- self-direction 75 ity 13; targeting problems by 91; self-interest, enlightened 74 teaching by 89–90, 116; therapeu- shame-attacking exercises 112 tic styles of 101–2, 105; use of social interest 75 force and energy by 111–13; use Socratic questioning 89 of humour by 81; warmth of 79 stoicism, emphasis of 7–8 therapy: parity in 80; psycho-edu- struggle, asserted 26–7 cational approach to 87–90 subjectivity 6 –7 t horoughgoingness, in REBT 132 s ymptom stress 55 t houghts: inferences about 61; rigid s ystematic desensitization 108 and extreme 64–5; scienti c 74 t hreats: protection from 11; and tasks 136 UNEs/HNEs 32–3 teaching: delivery of 89–90; rational philosophies 115–17; in u n bearability, negated 27 REBT 87–9 uncertainty, high tolerance of 75 theoretically consistent eclecticism unchangeability 6 –7 135–8 unconditional acceptance 71; of t herapeutic change 111–13; humans 42 compromises in 119–22 unconditional human worth 42–3 therapeutic eff ciency 131–3 unconditional life-acceptance t herapeutic progress, maintenance (ULA) 48, 116 of 132–3 unconditional other-acceptance t herapeutic relationship, in REBT (UOA) 48, 115

Downloaded by [New York University] at 06:45 14 August 2016 79–81 unconditional self-acceptance t herapeutic styles, variety of 101–5 (USA) 48, 115 t herapist acceptance 79–80 unconscious 11 therapist warmth 79 “understanding the person in the therapists: acceptance by 79–80; context of his or her problems” case formulation by 83; CBT 100, see UPCP approach

150 INDEX

u n healthy negative emotions warmth, of therapists 79 (UNEs) 31–3, 56–8, 88, 126–8 W o lpe, J. 108 u n healthy positive emotions working alliance theory 135–6 (UPEs) 33 worth bearing component 27–8 u n knowability 6 –7 UPCP approach 84–5 Young, H. 37

views 136 Z iegler, D.J. 5–6 Downloaded by [New York University] at 06:45 14 August 2016

151