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Strona główna Rational Emotive Behaviour Therapy: Distinctive Features (CBT Distinctive Features)
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The most comprehensive and clear explanation of what distinguishes Ellis's philosophically based REBT from Beck's CBT
28 August 2013 (22:05)
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Rational Emotive Behaviour Therapy Rational Emotive Behaviour Therapy (REBT) encourages the client to focus on their emotional problems in order to understand, challenge and change the irrational beliefs that underpin these problems. REBT can help clients to strengthen conviction in their alternative rational beliefs by acting in ways that are consistent with them and thus encourage a healthier outlook. This accessible and direct guide introduces the reader to REBT while indicating how it is different from other approaches within the broad cognitive behavioural therapy spectrum. Divided into two sections; The Distinctive Theoretical Features of REBT and The Distinctive Practical Features of REBT, this book presents concise, straightforward information in 30 key points derived from the author's own experience in the ®eld. Rational Emotive Behaviour Therapy: Distinctive Features will be invaluable to both experienced clinicians, and those new to the ®eld. It will appeal to psychotherapists and counsellors, together with students and practitioners who are keen to learn how REBT can be differentiated from the other approaches to CBT. Windy Dryden is Professor of Psychotherapeutic Studies at Goldsmiths College, London. Cognitive-behavioural 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 summarise the 30 main aspects of their approach divided into theoretical and practical features. The CBT Distinctive Features Series will be essential reading for psychotherapists, counsellors, and psychologists of all orientations who want to learn more about the range of new and developing c; ognitive-behavioural approaches. Titles in the series: Acceptance and Commitment Therapy by Frank Bond and Paul Flaxman Beck's Cognitive Therapy by Frank Wills Behavioral Activation Therapy by Jonathan Kanter, Andrew Busch and Laura Rusch Constructivist Psychotherapy by Robert A. Neimeyer Dialectical Behaviour Therapy by Michaela Swales and Heidi Heard Metacognitive Therapy by Peter Fisher and Adrian Wells Mindfulness-Based Cognitive Therapy by Rebecca Crane Rational Emotive Behaviour Therapy by Windy Dryden Schema Therapy by Jeffrey Young and Eshkol Rafaeli For further information about this series please visit www.routledgementalhealth.com/cbt-distinctive-features Rational Emotive Behaviour Therapy Distinctive Features Windy Dryden First published 2009 by Routledge 27 Church Road, Hove, East Sussex BN3 2FA Simultaneously published in the USA and Canada by Routledge 270 Madison Avenue, New York, NY 10016 Routledge is an imprint of the Taylor & Francis Group, an informa business This edition published in the Taylor & Francis e-Library, 2008. "To purchase your own copy of this or any of Taylor & Francis or Routledge's collection of thousands of eBooks please go to www.eBookstore.tandf.co.uk." Ø 2009 Windy Dryden 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. This publication has been produced with paper manufactured to strict environmental standards and with pulp derived from sustainable forests. 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. Rational emotive behaviour therapy : distinctive features / Windy Dryden. p. ; cm. Includes bibliographical references and index. ISBN 978-0-415-43085-2 (hardback) ± ISBN 978-0-415-43086-9 (pbk.) 1. Rational emotive behavior therapy. I. Title. [DNLM: 1. Psychotherapy, Rational-Emotive±methods. 2. Behavior Therapy±methods. 3. Emotions. WM 420.5.P8 D799rb 2009] RC489.R3D7888 2009 616.89©14±dc22 2008016707 ISBN 0-203-88908-8 Master e-book ISBN ISBN: 978-0-415-43085-2 (hbk) ISBN: 978-0-415-43086-9 (pbk) This book is dedicated to the life and legacy of Dr Albert Ellis, the founder of REBT Contents Introduction Part 1 THE DISTINCTIVE THEORETICAL FEATURES OF REBT 1 Post-modern relativism 2 REBT's position on human nature and other theoretical emphases: Distinctiveness in the mix 3 REBT's distinctive ABC model 4 Rigidity is at the core of psychological disturbance 5 Flexibility is at the core of psychological health 6 Extreme beliefs are derived from rigid beliefs 7 Non-extreme beliefs are derived from ¯exible beliefs 8 Distinction between unhealthy negative emotions (UNEs) and healthy negative emotions (HNEs) 9 Explaining why clients' inferences are highly distorted 10 Position on human worth ix 1 3 7 15 17 19 21 25 33 37 39 vii CONTENTS 11 Distinction between ego and discomfort disturbance and health 12 Focus on meta-emotional disturbance 13 The biological basis of human irrationality 14 Choice-based constructivism and going against the grain 15 Position on good mental health viii 43 53 57 63 65 Part 2 THE DISTINCTIVE PRACTICAL FEATURES OF REBT 16 The therapeutic relationship in REBT 17 Position on case formulation 18 Psycho-educational emphasis 19 Dealing with problems in order: (i) Disturbance; (ii) Dissatisfaction; (iii) Development 20 Early focus on iBs 21 Helping clients to change their irrational beliefs to rational beliefs 22 Use of logical arguments in disputing beliefs 23 Variety of therapeutic styles 24 Discourages gradualism 25 Change is hard work and the use of therapist force and energy 26 Emphasis on teaching clients general rational philosophies and encouraging them to make a profound philosophic change 27 Compromises in therapeutic change 28 Focus on clients' misconceptions, doubts, reservations, and objections to REBT 29 Therapeutic ef®ciency 30 Theoretically consistent eclecticism 117 123 127 References Index 133 137 69 71 75 79 83 87 89 93 99 103 105 109 113 Introduction At the time of writing (February, 2008), 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 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 exists a number of approaches that include the so-called ®rst wave, second wave and now third wave CBTbased 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 specialised or ``elegant'' REBT focused on the features that Ellis and other leading (past and present) REBT writers (e.g. Dryden, 2002; Grieger & Boyd, 1980; Wessler & Wessler, 1980) regard as preferential in the treatment of a variety of psychological disorders. The second, variously known as general ix INTRODUCTION 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 recognised that specialised 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 clinical 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 emphasise speci®c REBT and when it suits they can also claim that general REBT is really 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 aftermath of events at the Albert Ellis Institute, which led to the founder's disengagement from the Institute that bears 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 discussion boards have noted that the institute's website at various times 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 x INTRODUCTION clinical hypotheses derived from (speci®c) REBT as well as on its therapeutic effectiveness. Windy Dryden London & Eastbourne February, 2008 xi Part 1 THE DISTINCTIVE THEORETICAL FEATURES OF REBT THEORETICAL FEATURES OF REBT 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. This 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 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. 3 REBT: DISTINCTIVE FEATURES When REBT therapists do address the issues of the truth or otherwise of their clients' interpretations of ``reality'' (and we tend to do 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 was a horse in a race, it would be the favourite. However, and this is why this analogy that I have chosen is a good one, REBT therapists recognise 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 recognise and teach our clients to recognise 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! The philosophy enshrined in post-modern relativism is nicely encapsulated in the following quote by Jacques Barzun: Let us face a pluralistic world in which there are no universal churches, no single remedy for all diseases, no one way to 4 THEORETICAL FEATURES OF REBT teach or write or sing, no magic diet, no world poets, and no chosen races, but only the wretched and wonderfully diversi®ed human race. (1964, p. 184) 5 THEORETICAL FEATURES OF REBT 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 which Ellis (1978) ®rst outlined at the end of the 1970s. In this Point 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 philosophical and theoretical ideas other than that of post-modern relativism, which I discussed in Point 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 1. I include Ziegler's views here since he is both an REBT practitioner and a leading personality theorist who co-wrote a standard text on personality theories (Hjelle & Ziegler, 1992). It is not known the extent to which his is a consensus view among REBT 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: 7 REBT: DISTINCTIVE FEATURES 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 To what 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 ± Unchangeablity To what extent are people capable of fundamental change over time? Subjectivity ± Objectivity To what extent are people in¯uenced by subjective factors and to what extent by external, objective factors? Proactivity ± Reactivity To what extent do people generate their behaviour internally (proactivity) and to what extent do they respond to external stimuli (reactivity)? 8 THEORETICAL FEATURES OF REBT Homeostasis ± Heterostasis To what extent are humans motivated primarily to reduce tensions and maintain an inner homeostasis and to what extent are they motivated to actualise themselves? Knowability ± Unknowability To what extent is human nature fully knowable? 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 Figure 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) Phenomenological and stoic emphases REBT agrees, in large part, with the phenomenologists that we respond to events not as they are but more by how we see them. It also agrees, in large part, with the Stoic philosopher, Epictetus, who said that, ``Men are disturbed not by things but by their views of things''. These two emphases show how much REBT stresses cognition in human disturbance and health. However, as I make clear in Point 4, REBT emphasises in particular the role of rigid and extreme beliefs in human disturbance, which the phenomenologists and the Stoics do not. Thus, we have updated Epictetus's dictum to read: 9 REBT: DISTINCTIVE FEATURES 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 While 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 even includes strong negative responses to signi®cant life adversities like 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 (Point 8). 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. 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. 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, 10 THEORETICAL FEATURES OF REBT 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 emphasised 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. Psychodynamic features Although REBT was created, in part, out of Ellis's disaffection with psychoanalysis, it is easy to assume that as a result REBT has 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 discovered and brought to the client's conscious 11 REBT: DISTINCTIVE FEATURES 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 Point 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 upon their experiences and values, including their self-actualising potentialities'' (Ellis, 1980a, p. 327). It also shares the views of ethical humanism by encouraging people to emphasise human interest (self and social) over the interests of deities, material objects and lower animals. 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 12 THEORETICAL FEATURES OF REBT 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-generalisations, always±never thinking and the ``is'' of predication and of identity and helping people to change them. As noted earlier in this Point, because of its interactional or multifaceted view of mental events REBT does not neglect emotion and behaviour. However, as S. Nielsen (2006, personal communication) 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 words and phrases ``should'', ``ought'', ``must'', ``have to'', ``got to'', ``need to'', and ``supposed to''; ``awful'', ``horrible'', ``unbearable'', ``terrible''; and ``better person'', ``bad person'', ``jerk'', ``saint''; all can 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 territory and thus the meaning underpinning words is of more interest to REBT therapists than the words themselves. Having said that, there 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 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 Point 21). In addition, REBT places more 13 REBT: DISTINCTIVE FEATURES 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 Point 3: ``People are disturbed not by the systems in which they live, but by the rigid and extreme views that they take of these systems''. 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 example the principle of other-acceptance in REBT (see Points 7 and 10) 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. 14 THEORETICAL FEATURES OF REBT 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, 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 2 3 ``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, 2002) 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). As we will soon see, beliefs at ``B'' are either irrational (rigid and extreme) or rational (¯exible and non-extreme). ``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. 15 REBT: DISTINCTIVE FEATURES It is worth knowing in this context that when we consider some of the complexity of REBT's ABC framework, we discover that cognitions 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 Points what is perhaps REBT's most distinctive contribution; its position on irrational and rational beliefs at ``B''. 16 THEORETICAL FEATURES OF REBT 4 Rigidity is at the core of psychological disturbance All approaches to psychological treatment are based on how psychological disturbance is conceptualised. A major distinctive theoretical feature of REBT is that people are disturbed not by things but by the rigid views 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 rigid beliefs. Rigidity (also referred to as religiosity, dogmatism, absolutism and demandingness in the REBT literature) takes the form of musts, demands, absolute shoulds, needs, have to's, got to's, 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 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 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 17 REBT: DISTINCTIVE FEATURES 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. Multiplication 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 convinced 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 THEORETICAL FEATURES OF REBT 5 Flexibility is at the core of psychological health All approaches to psychological treatment also specify, either explicitly or implicitly, the factors that explain psychological health. If rigidity is deemed to be at the core of psychological disturbance in REBT, it follows that ¯exibility is 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 ¯exible beliefs. Flexibility builds upon 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 musts, these non-dogmatic preferences 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 . . . .'' ``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 19 REBT: DISTINCTIVE FEATURES 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. 20 THEORETICAL FEATURES OF REBT 6 Extreme beliefs are derived from rigid beliefs Another distinctive theoretical feature of REBT is that there are deemed to be three extreme beliefs that are derived from rigid beliefs. These are known as awfulising beliefs, low frustration tolerance (LFT) beliefs and depreciation beliefs. I will consider these one by one. Awfulising beliefs Awfulising beliefs are extreme ideas that we hold about how bad it is when our rigid demands are not met. Thus, as stated above, awfulising 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.'' Awfulising 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: 1 2 3 nothing could be worse; the event in question is worse than 100% bad; and no good could possibly come from this bad event. 21 REBT: DISTINCTIVE FEATURES Low frustration tolerance (LFT) beliefs Low frustration tolerance (LFT) beliefs are extreme ideas that we hold about the tolerability of events when our demands are not met. Thus LFT 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) . . . 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.'' ``(Life must be comfortable) . . . I can't stand it when it is uncomfortable.'' LFT 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: 1 2 3 If the frustration or discomfort continues to exist it is too hard for me to do anything about it. I will die or disintegrate if the frustration or discomfort continues to exist. 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. · 22 ``(I must be approved) . . . I am worthless if I am not approved.'' THEORETICAL FEATURES OF REBT · · ``(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: 1 2 3 A person (self or other) can legitimately be given a single global rating that de®nes their essence and the worth of a person is dependent upon conditions that change (e.g. our worth goes up when we do well and goes down when we don't do well). Life can legitimately be given a single rating that de®nes its essential nature and that the value of life varies according to what happens within it (e.g. the value of life goes up when something fair occurs and goes down when something unfair happens). 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. 23 THEORETICAL FEATURES OF REBT 7 Non-extreme beliefs are derived from flexible beliefs In the same way as REBT theory states that three extreme beliefs are derived from rigid beliefs, it holds that three non-extreme beliefs are derived from ¯exible beliefs. These are known as antiawfulising beliefs, high frustration tolerance (HFT) beliefs and acceptance beliefs. I will now consider these one by one. Anti-awfulising beliefs Anti-awfulising beliefs are non-extreme ideas we hold about how bad it is when our non-dogmatic preferences are not met. Thus, non-awfulising 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.'' Two components of anti-awfulising beliefs If you look carefully at the anti-awfulising beliefs (i.e. the ones that are not in parentheses) you will see that they are made up of two components. 25 REBT: DISTINCTIVE FEATURES ``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 awfulising'' 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 awfulising'' component. These are shown in italics below: · · · ``It's bad if I am not approved, but not terrible.'' ``When you don't treat me fairly it's really bad, but not awful.'' ``If life is uncomfortable, that's very bad, but not the end of the world. Anti-awfulising 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: 1 2 3 Things could always be worse. The event in question is less than 100% bad. Good could come from this bad event. High frustration tolerance (HFT) beliefs High frustration tolerance (HFT) beliefs are non-extreme ideas that you hold about the tolerability of events when your 26 THEORETICAL FEATURES OF REBT non-dogmatic preferences are not met. Thus, HFT beliefs are derivatives from your non-dogmatic preferences when these 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 dif®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.'' Three components of high frustration tolerance (HFT) beliefs If you look carefully at the high frustration tolerance beliefs (i.e. the ones that are not in parentheses) you will see that they are made up of three components. ``Asserted struggle'' component The ®rst component puts forward the idea that it is dif®cult tolerating not getting what we want and is what I call the ``asserted struggle'' component. · · · ``When I am not approved, it is dif®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 . . . .'' 27 REBT: DISTINCTIVE FEATURES ``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 dif®cult to bear, but I can bear it . . . .'' ``When you don't treat me fairly it's really hard to tolerate, but I can tolerate it . . . .'' ``If life is uncomfortable, that's hard to stand, but I can stand it . . . .'' ``Worth bearing'' component The third component addresses the point that it is often worth it to you to tolerate the situation where 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 dif®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.'' ``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.'' ``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.'' HFT 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 28 THEORETICAL FEATURES OF REBT is non-extreme in the sense that we believe at the time something very much like the following: 1 2 3 4 It is hard, but not too hard if the frustration or discomfort continues to exist. I will struggle if the frustration or discomfort continues to exist, but I will neither die nor disintegrate. I will not lose the capacity to experience happiness if the frustration or discomfort continues to exist, although this capacity will be temporarily diminished. 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 non-dogmatic preferences 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 doesn't have to be the way I want it to be) . . . If life is uncomfortable it is only uncomfortable in this respect and doesn't prove that the world is a rotten place. The world is a complex place where many good, bad and neutral things happen.'' 29 REBT: DISTINCTIVE FEATURES Three components of acceptance beliefs 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 bad . . . . When you don't treat me fairly that is very regrettable . . . . If life is uncomfortable it is only uncomfortable in this respect . . . . ``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 worthless . . . .'' ``When you don't treat me fairly that is very regrettable, but you are not a bad person . . . .'' ``If life is uncomfortable it is only uncomfortable in this respect and doesn't prove that the world is a rotten place . . . .'' ``Assertion of acceptance'' component 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. These are shown in italics below: 30 THEORETICAL FEATURES OF REBT · · · ``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 and 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: 1 2 3 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 upon conditions that change (e.g. my worth stays the same whether or not I do well). The 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). 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. 31 THEORETICAL FEATURES OF REBT 8 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 follows: UNEs HNEs Anxiety Depression Guilt Shame Hurt Unhealthy anger Unhealthy jealousy Unhealthy envy Concern Sadness Remorse Disappointment Sorrow Healthy anger Healthy jealousy Healthy envy 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 nonextreme) 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 33 REBT: DISTINCTIVE FEATURES 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 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 are qualitatively different from HNEs. For example, using the above list, 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 about that adversity. Other approaches to CBT would consider it to be appropriate and legitimate to help a person 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 with less intensity rather than think rationally. As I mentioned earlier, we don't have a 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 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) and/or his subsequent thinking (overestimating the negativity of the consequences if the threat were to materialise in anxiety; making a realistic estimation of these consequences in concern). While less frequently mentioned in the literature, REBT theory also distinguishes between unhealthy positive emotions 34 THEORETICAL FEATURES OF REBT (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. By contrast, healthy positive emotions (such as delight) tend to stem from non-dogmatic 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. 35 THEORETICAL FEATURES OF REBT 9 Explaining why clients' inferences are highly distorted One of the dif®culties 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 dif®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 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 conceptualised 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 & Klosko, 1993) also makes this point, only REBT does this in the context of the ABC framework for which it is known. 37 THEORETICAL FEATURES OF REBT 10 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 The philosophy of conditional human worth comprises a number of positions: 1 It implies that humans are simple organisms that merit a global evaluation. 39 REBT: DISTINCTIVE FEATURES 2 3 4 5 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. It makes the error of over-generalisation when it bases a person's worth on a single or small number of traits, characteristics and/or behaviours (e.g. ``My acting poorly means that I am bad''). It implies that humans are perfectible. 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 2 3 4 5 40 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. It states that a person can accept self or others unconditionally, i.e. whether or not certain desired conditions are present. It avoids making the error of over-generalisation 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''). It acknowledges the fallibility and non-perfectability of humans. It protects people from emotional disturbance. Much (but far from all) emotional disturbance stems from assigning conditional, global evaluations of worth to humans. In THEORETICAL FEATURES OF REBT unconditional acceptance of humans, such assignations are not made. 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 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 2 3 4 Humans can be given global evaluations with respect to worth. It is best to give humans positive global evaluations with respect to worth. 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''). 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 above 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. 41 THEORETICAL FEATURES OF REBT 11 Distinction between ego and discomfort disturbance and health Albert Ellis and other REBT theorists have proposed somewhat different approaches to distinguishing between different fundamental types of disturbance and health. In this Point I will review three such approaches which 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 nonego disturbance (Dryden, 1999). Ellis ®rst made this distinction clear 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 above). 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 I should rot in hell as a subhuman (devil). 43 REBT: DISTINCTIVE FEATURES 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, demands made on other people either involve 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. Ego health The most common form of ego health is unconditional selfacceptance (as discussed above). This occurs when I hold 44 THEORETICAL FEATURES OF REBT preferences about myself, but do not demand that I must achieve 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 selfrating tends to be conditional on doing good things, being loved and approved, and so on. Ego health is also found in non-dogmatic preferences 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 non-dogmatic preferences 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 comfort 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''. Discomfort tolerance is central to dealing with a range of psychological problems and is a hallmark of what is known as psychological resilience (Reivich & Shatte, 2002) in that it encourages people to face up to life adversities and cope with them head on, with dif®culty to be sure, particularly in the short term, but ultimately to good effect in the longer term. Discomfort 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 meaningful long-term goals while tolerating the deprivation of attractive short-term goals, which are self-defeating in the longer term. 45 REBT: DISTINCTIVE FEATURES According to REBT theory, non-dogmatic preferences 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 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 liferelated disturbance and health In his later writings, Ellis moved away from emphasising the distinction between ego and discomfort disturbance and health towards distinguishing between what I have called here selfrelated, other-related and life-related disturbance and health (e.g. Ellis, 2004). My view is that Ellis did this to capitalise 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) recently 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 Point 7. 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: 46 THEORETICAL FEATURES OF REBT · · · SD (self-depreciation) where the person is depreciating him- or herself in some way; OD (other-depreciation) where the person is depreciating another person or persons in some way; and LD (life-depreciation) where the person is depreciating life in some way. Whether one conceptualises 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 2 ego and discomfort or self, other(s) or life. I have stressed this in Points 6 and 7. 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 Ò 2 disturbance and health matrices. The 3 Ò 2 disturbance matrix Dryden et al. (1997) argued that it is possible to take the three basic ``musts'' (about self, others and life) and the two fundamental disturbances (i.e. ego and discomfort) to form a 3 Ò 2 disturbance matrix (see Figure 2). I will now discuss the six types of disturbance yielded by this matrix. (A) Ego disturbance ± Demands about self In this type of disturbance, it is quite clear that the person concerned is making demands upon herself (in this case) and 47 REBT: DISTINCTIVE FEATURES Ego Discomfort I must . . . A B You must . . . C D Life must . . . E F Figure 2 The 3 Ò 2 disturbance matrix the main issue is her attitude towards herself. The major derivative from the ``must'' 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.'' (B) Discomfort disturbance ± Demands about self Here, the person makes demands 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 ± Demands about others In this example, the person is making demands 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: 48 THEORETICAL FEATURES OF REBT · ``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 ± Demands about others Here, the person is making demands upon 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.'' (E) Ego disturbance ± Demands about life conditions On the surface, the person is making demands 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 ± Demands about life conditions In this ®nal kind of disturbance we are dealing with a more impersonal form of low frustration tolerance. 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.'' 49 REBT: DISTINCTIVE FEATURES Ego Discomfort I want . . . but I don't have to . . . A B I want you to . . . but you don't have to . . . C D I want life to . . . but it doesn't have to . . . E F Figure 3 The 3 Ò 2 health matrix The 3 Ò 2 health matrix Extrapolating from Dryden et al.'s (1997) 3 Ò 2 disturbance matrix, it is possible to develop a 3 Ò 2 health matrix (see Figure 3). I will now discuss the six types of health yielded by this matrix. (A) Ego health ± Non-dogmatic preferences about self Here, the person concerned holds non-dogmatic preferences concerning herself and the main derivative from this ¯exible belief is some aspect of 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.'' ``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 ± Non-dogmatic preferences about self Here, the person holds non-dogmatic preferences about herself, but the real issue concerns her attitude towards discomfort. For example: 50 THEORETICAL FEATURES OF REBT · ``If I don't obtain my degree, I might have to settle for some kind of tedious, manual job. I want to achieve more that 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 ± Non-dogmatic preferences about others In this example, the person holds non-dogmatic preferences about the behaviour (or its absence) of another, but the real issue centres round her attitude towards herself. For example: · ``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.'' (D) Discomfort tolerance ± Non-dogmatic preferences about others Here, the person holds non-dogmatic preferences 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 dif®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 ± Non-dogmatic preferences about life conditions On the surface, the person is holding non-dogmatic preferences 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.'' 51 REBT: DISTINCTIVE FEATURES (F) Discomfort tolerance ± Non-dogmatic preferences about life conditions In this ®nal type of health we are dealing with a more impersonal form of high frustration tolerance. For example: · · 52 ``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 can stand the frustration if it did.'' ``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.'' THEORETICAL FEATURES OF REBT 12 Focus on meta-emotional disturbance While other approaches to CBT do recognise that people disturb themselves about their disturbances, none focus on this phenomenon as much as REBT. The fact that humans disturb themselves about their disturbance has been variously referred to as symptom stress (Walen, DiGiuseppe, & Dryden, 1992), 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-emotional disturbance more closely, we ®nd that it has a number of different features. UNEs at ``A''; UNEs at ``C'' When we disturb ourselves at ``C1'' about the adversities in our lives at ``A1'', we can then focus on these unhealthy negative emotions (UNEs) and disturb ourselves about them. When we do this, these UNEs, which were originally located at ``C1'', become adversities at ``A2'' and our disturbed emotional responses to them are located at ``C2''. This is shown below: A1 = Original adversity B1 = Irrational belief C1 = UNE1 A2 = UNE1 53 REBT: DISTINCTIVE FEATURES B2 = Irrational belief C2 = UNE2 Inferences about UNEs at ``A''; UNEs at ``C'' We not only disturb ourselves about our unhealthy negative emotions when we experience them, we also disturb ourselves about the inferences we make about these emotions. This is shown below: A1 = Original adversity B1 = Irrational belief C1 = UNE 1 A2 = Inference about UNE1 B2 = Irrational belief C2 = UNE2 For example, let's suppose that I feel anxious about giving a poor public speech. I then make myself anxious about the anxiety that I ®rst experience. Now I can either feel anxious about the feeling of anxiety (which I have just discussed above) or I can feel anxious about my anxiety because I take it that it means that I am losing control which is my inference. Here I am more anxious about losing control than I am about the anxiety itself. These two different scenarios are shown opposite: 54 THEORETICAL FEATURES OF REBT A1 = Doing poorly at public speech A1 = Doing poorly at public speech B1 = Irrational belief B1 = Irrational belief C1 = Anxiety C1 = Anxiety A2 = Feelings of anxiety A2 = Losing control (inference about C1) B2 = Irrational belief B2 = Irrational belief C2 = Increased anxiety C2 = Increased anxiety 55 THEORETICAL FEATURES OF REBT 13 The biological basis of human irrationality Ellis (1976) has argued that humans have two basic biological tendencies. First, we have a tendency towards irrationality; 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! Ellis (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 rationality were as ubiquitous as human irrationality appears to be. It would be very dif®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 57 REBT: DISTINCTIVE FEATURES rarely smoke and would tend 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 nonextreme 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 dif®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. If we were strongly biologically prone to retain ¯exible and nonextreme beliefs in the face of our very strong desires not being met, then we would ®nd it very dif®cult to think in rigid and 58 THEORETICAL FEATURES OF REBT extreme ways under these circumstances and would tend not to do so even if strongly encouraged to do so by our culture. 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 was 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 dif®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. On the other hand, 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 Many human irrationalities actually go counter to the teachings of parents, peers and the mass media (for example, people are 59 REBT: DISTINCTIVE FEATURES 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 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 actualised 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. Also, 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 recent beginning of the year ad campaign from Boots the Chemist in Britain urged its customers to make one small change, in recognition of the 60 THEORETICAL FEATURES OF REBT failure experienced by most people in tackling several areas of poor self-discipline at once! The ease with which we lapse and relapse, the ease with which we replace one irrationality with another and the great dif®culty we have at making several changes at once, all point again to the biological basis of this form of irrationality. As a species, we ®nd it inordinately dif®cult to think and act rationally in the ®rst place and to acquire and, particularly, maintain rational thinking and action in the second place. 61 THEORETICAL FEATURES OF REBT 14 Choice-based constructivism and going against the grain While there are a number of constructivistic approaches to CBT (see Dobson, 2001), REBT's position on the issue of constructivism is distinctive in that it emphasises that we create or construct our rigid and extreme ideas from our preferences. I have already argued above that this constructivistic tendency is biologically based. What is important to factor in here is the point that I have already made; namely, that we also have a biologically-based tendency to think rationally about life's adversities. As such, we have a 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 argued that we ®nd it very easy 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 dif®culty we have in constructing and remaining with non-extreme ideas when our desires are unmet. However dif®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 dif®cult to 63 REBT: DISTINCTIVE FEATURES 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 dif®cult circumstances is a hallmark of REBT. 64 THEORETICAL FEATURES OF REBT 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, on the other hand, 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 remediation of psychological disturbance, it also strives to help clients to work towards being as psychologically healthy as possible. This is how REBT conceptualises 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 utilising 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. Flexibility and anti-extremism People with GMH have a belief system made up largely of ¯exible and non-extreme beliefs. When they do disturb themselves by holding rigid and extreme beliefs they recognise 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. 65 REBT: DISTINCTIVE FEATURES 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 awfulise, 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. By de®nition such people are open to change and are minimally defensive. Scientific 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 evaluating 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. They 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. Finally, they accept the fact that Utopias are probably unachievable and also recognise that it is unlikely that they will get everything 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 themselves 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. 66 THEORETICAL FEATURES OF REBT Social interest People with GMH also realise 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 co-operate 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 realise that they tend to be healthier and happier when they are vitally absorbed in something outside of themselves. REBT does not have anything relevant to say about what these meaningful pursuits should be as there is an enormous range of such 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). 67 REBT: DISTINCTIVE FEATURES 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 high frustration 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. 68 Part 2 THE DISTINCTIVE PRACTICAL FEATURES OF REBT PRACTICAL FEATURES OF 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 suf®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 Ellis (in Dryden, 1997) has 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 holds 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 important 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 therapists convey that they 71 REBT: DISTINCTIVE FEATURES 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 Point 10. 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 Point 10. Informality REBT therapists tend towards informality of therapeutic style although we can be formal when required. This informality communicates 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 conceptualising clients' problems and effecting change in these problems, REBT therapists are decidedly superior to their clients . . . or at least (ideally) should be. However, when it comes to their value as human beings, then REBT's 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! 72 PRACTICAL FEATURES OF REBT Humour There 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 emphasised 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. 73 PRACTICAL FEATURES OF REBT 17 Position on case formulation Persons (1989), in a seminal book, highlighted the importance of adopting a case-formulation (sometimes called caseconceptualisation) approach to the practice of CBT. A case formulation 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 conceptualisation 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 Point 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 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 75 REBT: DISTINCTIVE FEATURES formulation of the ``case'' as they go rather than structuring therapy into formulation±intervention stages. As with many other issues, Ellis is the driving force here. When he started his career he became dissatis®ed with an approach to therapy that saw therapeutic intervention being dependent upon a thorough assessment of clients' psychopathology 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 inef®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 organisation'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 gotten 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 supervision 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 gotten 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 manifest, 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