Cognitive Behavior Therapy

 Traditional behavior therapy has broadened and largely moved in the direction of cognitive behavior therapy.  Albert Ellis’s rational emotive behavior therapy (REBT) , Beck’s cognitive therapy, and Meichenbaum’s cognitive behavior therapy are several of the more prominent cognitive behavioral approaches.  Cognitive behavior therapy combines both cognitive and behavioral principles and methods in a short-term treatment approach.

The cognitive behavioral approaches share these attributes:

1. a collaborative relationship between client and therapist

2. the premise that psychological distress is largely a function of disturbances in cognitive processes

3. a focus on changing cognitions to produce desired changes in affect and behavior, and

4. a generally time-limited and educational treatment focusing on specific and structured target problems.

All of the cognitive behavioral approaches are based on a structured psycho-educational model, and they all emphasize the role of homework, place responsibility on the client to assume an active role both during and outside of the therapy sessions, and draw from a variety of cognitive and behavioral strategies to bring about change.  Cognitive behavior therapy is based on the assumption that a reorganization of one’s self-statements will result in a corresponding reorganization of one’s behavior.  Behavioral techniques such as operant conditioning, modeling, and behavioral rehearsal can also be applied to the more covert and subjective processes of thinking and internal dialogue.

ELLIS’ RATIONAL EMOTIVE BEHAVIOR THERAPY

REBT is formed on the basic assumption that people contribute to their own psychological problems, as well as to specific symptoms, by the way they interpret events and situations.  REBT is based on the assumption that cognitions, emotions, and behaviors interact significantly and have a reciprocal cause-and-effect relationship.  REBT has consistently emphasized all three of these modalities and their interactions, thus, qualifying it as an integrative approach.

REBT’s basic hypothesis is that our emotions stem mainly from our beliefs, evaluations, interpretations, and reactions to life situations.  Through the therapeutic process, clients learn skills that give them the tools to identify and dispute irrational beliefs that have been acquired and self-constructed and are now maintained by self-indoctrination.  They learn how to replace such ineffective ways of thinking with effective and rational cognitions, and as a result they change their emotional reactions to situations.  The therapeutic process allows clients to apply REBT principles of change not only to a particular presenting problem but also to many other problems in life or future problems they might encounter.

The focus of REBT is on working with thinking and acting rather than primarily with expressing feelings.  Therapy is seen as an educational process.  The therapist functions in many ways like a teacher, especially in collaborating with a client on home-work assignments, and in teaching strategies for straight thinking; and the client is a learner; who practices the skills discussed in therapy in everyday life.  REBT does not place much value on free association, working with dreams, focusing on the client’s past history, endlessly expressing feelings, or dealing with transference phenomena.

View of Human Nature:

Is based on the assumption that human beings are born with a potential for both rational, or “straight” thinking and irrational, or “crooked” thinking.  People have predispositions for self-preservation, happiness, thinking and verbalizing, loving, communion with others, and growth and self-actualization.  They also have propensities for self-destruction, avoidance of thoughts, procrastination, endless repetition of mistakes, superstition, intolerance, perfectionism and self-blame, and avoidance of actualizing growth potentials.  REBT attempts to help them accept themselves as creatures who will continue to make mistakes yet at the same time learn to live more at peace with themselves.  Ellis assumes that we are self-talking, self-evaluating, and self-sustaining.  We develop emotional and behavioral difficulties when we mistake simple preferences for dire needs.

View of Emotional Disturbance:

We originally learn irrational beliefs from significant others during childhood.  We create irrational dogmas and superstitions by ourselves.  We actively reinforce self-defeating beliefs by the processes of autosuggestion and self-repetition and by behaving as if they are useful.  It is largely our own repetition of early-indoctrinated irrational thoughts that keeps dysfunctional attitudes alive and operative within us.

Ellis contends that people do not need to be accepted and loved, even though this may be highly desirable.  He insists that blame is at the core of most emotional disturbances.  To recover from a neurosis or a personality disorder, we had better stop blaming ourselves and others.  Instead, it is important that we learn to accept ourselves despite our imperfections.  We have strong tendencies to escalate our desires and preferences into dogmatic “shoulds” “musts,” “oughts,” demands, and commands.  Such demands create disruptive feelings and dysfunctional behavior.

• I must have love or approval from all the significant people in my life.

• It’s easier to avoid facing life’s difficulties and responsibilities than to undertake more rewarding forms of self-discipline.

A-B-C Theory of Personality:

A is the existence of a fact, an event, or the behavior or attitude of an individual.  C is the emotional and behavioral consequence or reaction of the individual; the reaction can be either healthy or unhealthy.  A (the activating event) does not cause C (the emotional consequence).  Instead B, which is the person’s belief about A, largely causes C, the emotional reaction.  Showing people how they can change the irrational beliefs that directly “cause” their disturbed emotional consequences is the heart of REBT.

An emotional disturbance is fostered by the self-defeating sentences clients continually repeat to themselves, such as “I am totally to blame for the divorce.” “I am a miserable failure, and everything I did was wrong,”  Ellis repeatedly makes the point that “you mainly feel the way you think.”

There are three components of the disrupting process:  detecting, debating, and discriminating.  Clients learn how to detect their irrational beliefs, particularly their absolutist “shoulds” and “musts,” their “awfulizing,” and their “self-downing.”  Clients then debate their dysfunctional beliefs by learning how to logically and empirically question them and to vigorously argue themselves out of and act against believing them.  Finally, clients learn to discriminate irrational (self-defeating) beliefs from rational (self-helping) beliefs.

A new and effective belief system consist of replacing unhealthy thoughts with healthy ones.  If we are successful in doing this, we also create F, a new set of feelings.  Instead of feeling seriously anxious and depressed, we feel healthily sorry and disappointed in accord with a situation.

Therapeutic Goals:

According to Ellis, we have a strong tendency not only to rate our acts and behaviors as “good” or “bad,” “worthy” or “unworthy” but also to rate ourselves as a total person on the basis of our performances.  Therefore, most cognitive behavior therapists have the general goal of teaching clients how to separate the evaluation of their behaviors from the evaluation of themselves – their essence and their totality – and how to accept themselves in spite of their imperfections.  The goal and destination of clients is to minimize their emotional disturbances and self-defeating behaviors by acquiring a more realistic and workable philosophy of life.  A basic goal is to teach client show to change their dysfunctional emotions and behaviors into healthy ones.  As clients become more able to accept themselves, they are more likely to unconditionally accept others.

Therapist’s Function and Role:

The first step of the therapist is to show clients that they have incorporated many irrational “shoulds,” “oughts,” and “musts.”  Clients learn to change their rigid “musts” into preferences.  The therapist encourages and often persuades clients to engage in activities that will counter their self-defeating beliefs.

A second step in the therapeutic process is to demonstrate that clients are keeping their emotional disturbances active by continuing to think illogically and unrealistically.  To get beyond client’s mere recognition of irrational thoughts, the therapist takes a third step – helping clients modify their thinking and abandon their irrational ideas.  The therapist assists clients in understanding the vicious circle of the self-blaming process, which also changes their self-defeating behaviors.

The fourth step is to challenge clients to develop a rational philosophy of life so that in the future they can avoid becoming the victim of other irrational beliefs.  What is desirable, then, is for the therapist to dispute the core of the irrational thinking and to teach clients how to substitute rational beliefs and behaviors for irrational ones.  

The therapist mainly employs a persuasive methodology that emphasizes education.  The therapist:

• Encourages clients to discover a few basic irrational ideas that motivate much disturbed behavior

• Show how these beliefs are inoperative and how they will lead to future emotional and behavioral disturbances.

• Challenges clients to change their self-sabotaging beliefs.

• Uses several cognitive, emotive, and behavioral methods to help clients work directly on their feelings and to act against their disturbances.

Client’s Experience in Therapy:

The clients role in REBT is that of a learner and doer.  Psychotherapy is viewed as a reeducative process whereby the client learns how to apply logical thought, experiential exercises, and behavioral homework to problem solving and emotional change.

The therapeutic-process focuses on clients’ experiences in the present.  REBT mainly emphasizes here-and-now experiences and clients’ present ability to change the patters of thinking and emoting that they constructed earlier.  The therapist does not devote much time to exploring clients’ early history and making connections between their past and present behavior.  They are presently disturbed because they still believe in and act upon their self-defeating view of themselves and their world.

Clients learn that by working hard and carrying out behavioral homework assignments they can minimize faulty thinking, which leads to disturbances in feeling and behaving.  Homework is carefully designed and agreed upon and is aimed at getting clients to carry out positive actions that induce emotional and attitudinal change.  These assignments are checked in later sessions, and clients learn effective ways to dispute self-defeating thinking.  Toward the end of therapy, clients review their progress, make plans, and identify strategies for dealing with continuing or potential problems.

Relationship Between Therapist and Client:

An intense relationship between therapist and client is not required.   Therapists show their full acceptance by refusing to evaluate their clients as persons while at the same time being willing to honestly confront clients’ faulty thinking and self-destructive behaviors.

Ellis believes that too much warmth and understanding can be counter-productive, fostering a sense of dependence for approval from the therapist.  Ellis builds rapport with his clients by showing them that he has great faith in their ability to change themselves and that he has the tools to help them do this.

Rational emotive behavior therapists are often open and direct in disclosing their own beliefs and values.  Transference is not encouraged and when it does occur, the therapist is likely to confront it.  The therapist wants to show that a transference relationship is based on the irrational belief that the client must be liked and loved by the therapist or parent figure.

The Practice of REBT:

Therapists use a variety of cognitive, affective, and behavioral techniques, tailoring them to individual clients.  What follows is a brief summary of the major cognitive, emotive, and behavioral techniques Ellis describes.  REBT relies heavily on thinking, disputing, debating, challenging, interpreting, explaining, and teaching.

Cognitive methods.

Disputing irrational belief:  The therapist actively disputes clients’ irrational beliefs and teaches them how to do this challenging on their own.  Clients go over a particular “must,” “should,” or “ought” until they no longer hold that irrational belief, or at least until its is diminished in strength.

Doing cognitive homework:  REBT clients are expected to make lists of their problems, look for their absolutist beliefs, and dispute these beliefs.  Homework assignments are a way of tracking down the absolutist “shoulds” and “musts” that are part of their internalized self-messages.  In carrying out homework, clients are encouraged to put themselves in risk-taking situations that will allow them to challenge their self-limiting beliefs.  Because therapy is seen as an educational process, clients are also encouraged to read REBT self-help books.  Making changes is hard work, and doing work outside the sessions is or real value in revising clients’ thinking, feeling, and behavior.

Changing one’s language:  REBT contends that imprecise language is one of the causes of distorted thinking processes.  Clients learn that “musts,” “oughts,” and “shoulds” can be replaced by preferences.  Instead of saying “It would be absolutely awful if . . . ,” they learn to say “It would be inconvenient if . . . “.  Clients who use language patterns that reflect helplessness and self-condemnation can learn to employ new self-statements, which help them think and behave differently.  As a consequence, they also begin to feel differently.

Using humor:  Emotional disturbances often result from taking oneself too seriously and losing one’s sense of perspective and humor over the events of life.  Humor shows the absurdity of certain ideas that clients steadfastly maintain, and it can be of value in helping clients take themselves much less seriously.

Emotive techniques.

A variety of emotive procedures are used including unconditional acceptance, rational-emotive role playing, modeling, rational-emotive imagery, and shame-attacking exercises.  These strategies are used both during the therapy sessions and as homework assignments in daily life.  Their purpose is not simply to provide a cathartic experience but to help clients change some of their thoughts, emotions, and behaviors.

Rational-emotive imagery:  This technique is a form of intense mental practice designed to establish new emotional patterns.  Clients imagine themselves thinking, feeling, and behaving exactly the way they would like to think, feel and behave in real life.  They can also be shown how to imagine one of the worst things that could happen to them, how to feel unhealthily upset about this situation, how to intensely experience their feelings, and then how to change the experience to a healthy negative feeling.

Role playing:  There are both emotional and behavioral components in role playing.  The therapist often interrupts to show clients what they are telling themselves to create their disturbances and what they can do to change their unhealthy feelings to healthy ones.  Clients can rehearse certain behaviors to bring out what they feel in a situation.  The focus is on working through the underlying irrational beliefs that are related to unpleasant feelings.

Shame attacking exercises.  These are exercises to help people reduce shame over behaving in certain ways.  Ellis thinks that we can stubbornly refuse to feel ashamed by telling ourselves that it is not catastrophic if someone thinks we are foolish.  The exercises are aimed at increasing self-acceptance and mature responsibility, as well as helping clients see that much of what they think of as being shameful has to do with the way they define reality for themselves.  Clients eventually learn that they often have no reason for continuing to let others’ reactions or possible disapproval stop them from doing the things they would like to do.

Use of force and vigor:  Ellis has suggested the use of force and energy as a way to help clients go from intellectual to emotional insight.  Clients are also shown how to conduct forceful dialogues with themselves in which they express their unsubstantiated beliefs and then powerfully dispute them.

Behavioral techniques.

REBT practitioners use most of the standard behavior therapy procedures, especially operant conditioning, self-management principles, systematic desensitization, relaxation techniques, and modeling.  These assignments are done systematically and are recorded and analyzed on a form.  Many involve desensitization, skill training, and assertiveness training.
Dr. Rebecca Curtis

www.auburn.edu/cspd/fall04/counseling