Tag Archives: Cognitive Behavior Therapy

Rational Emotive Behavior Therapy

REBT-Rational Emotive Behavior Therapy

Rational-Emotive Behavior Therapy (REBT) was developed by Albert Ellis. Dr. Ellis  who was originally trained in psychoanalysis. After completing his doctoral work he began treating patients in New York City. He became frustrated by the limited progress his psychotherapy patients were making in psychoanalysis.

He then decided to turn to one of his earliest interests, philosophy. He went back and read Stoic philosophy as well as eastern philosophy. He based a new system of psychotherapy on much of this work. The hypothesis that made the most sense to him was that our emotional pain is not the product exclusively of the situation, but also our thinking about the situation, ourselves, life, and the future.

From this view of human emotion, he developed the ABC model, which is used by many Cognitive Behavior Therapists (CBT) today. In REBT, “A” stands for activating events. These are the situations, real or imagined, that trigger, or activate, our beliefs. “Bs” are these beliefs, which can be rational (or helpful) or irrational (unhelpful). Over the years the kinds and number of irrational beliefs he identified changed. The most refined version of REBT beliefs includes four core irrational beliefs and four alternative rational beliefs.

Irrational Beliefs

Demandingness (DEM)
Low frustration Tolerance (LFT)
Awfulizing (AWF)
Global Evaluations (Self-downing; SD)

Rational Beliefs

High Frustration Tolerance (HFT)
Badness rating
Unconditional Self-acceptance (USA) or Unconditional Other/Life Acceptance

REBT posits that the combination of activating events (As) and beliefs (Bs) produce consequences or the “Cs.” The situation (A) is interpreted and evaluated (B), which results in an emotional consequence (C). For example, if a student receives a failing grade on her exam (A), and she believes this proves it, “I’m a failure (B).” She might then feel depressed  (or depressed and anxious) (C). That particular consequence is an emotional consequence (Ce). When feeling that way, certain behaviors become more likely than others. When we are depressed, staying in bed may become more likely than going to the gym. These are behavioral consequences (Cb).

REBT therapists target behavior change largely by identifying the events, irrational beliefs, and then emotions that precede the behavior they want to change. The most common intervention is to dispute (D) the irrational beliefs, i.e., asking challenging questions to reduce the strength of the irrational belief. Then once the client no longer believes the irrational beliefs as strongly, an alternative rational belief can be selected to rehearse (E; effective new philosophy).

In this case, an REBT therapist may help the client, through disputation, to recognize that even though she may have failed one exam, it does not logically follow that she becomes a failure. It may take a great deal of effort on the part of the therapist and even more on the part of the client to get there. The hope is, she will eventually let go of the belief that she is a failure, and can rehearse and practice behaviors to support the rational alternative. The rational alternative to the global evaluation/self-downing (“I”m a failure”) belief would be unconditional self-acceptance (USA). If she can accept herself unconditionally, regardless of what grades she receives, she can be more emotionally stable. Without the thinking that “I’m a failure” could be looming, the client can become less anxious she will become depressed again. Now if she fails at something, she can practice unconditional self-acceptance, and tell herself, “even though I fail at things, I do not become a failure– I do not become what I do.” This new attitude can inoculate her against self-defeating thoughts that “dog” her. And this new accepting attitude can reduce or prevent feelings of depression or anxiety that she may become depressed again. Without the anxiety she may be able to concentrate more when studying, hopefully decreasing the possibility of failing future exams.

REBT therefore aims to change beliefs in order to reduce not only future negative emotions, thereby making adaptive behaviors, e.g., effective studying, more likely, but also intends to reduce failures. Since intense negative emotions often lead to poor judgement, impulsive actions, or unhealthy coping, e.g., procrastination, drinking, overeating, etc… REBT aims to improve behaviors and life circumstances over time, by first changing thinking and feelings. So while it is a cognitive model of psychotherapy, it by no means ignores improving behaviors and life circumstances. REBT simply believes the closest target to emotion is cognition, and changing that link alters for the better the entire chain reaction, resulting in better behaviors and eventually improved life circumstances.

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[fontawesome icon=”fa-file-text-o” circle=”no” size=”medium” iconcolor=”#000000″ ] REBT Self-help Form – CBT Worksheet

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REBT References

A synopsis of rational-emotive behavior therapy (REBT); Fundamental and applied research. David, Daniel; Szentagotai, Aurora; Eva, Kallay; Macavei, Bianca
Journal of Rational-Emotive & Cognitive-Behavior Therapy, Vol 23(3), 2005, 175-221.

couples therapy

Couples Therapy Part 2

Is this the Best Relationship I can have?

The previous blog on couples therapy reviewed the efficacy rates of couples therapy. It is clear that some therapies have the potential to help the majority of couples improve. This is good news, but there may be even more pressing questions for husbands, wives, boyfriends, and girlfriends, i.e., is what I’m experiencing in my relationship normal? Is how I’m being treated typical? Do I deserve more, do healthier relationships really exist, or do they all descend into what I’m experiencing? Maybe this is as good as it gets. When is the time for change (either improving this relationship by each partner learning new behaviors or improving life by leaving the partner), and when is the time for accepting what I have?

Regardless of your creed, hopefully the serenity prayer’s request to know the difference between the things we can change and those that require acceptance is wisdom we would all like to acquire. Both change and acceptance can be difficult and applying them to the wrong things is certainly a waste of resources. So how do we know if the relationship could use some work in terms of change or acceptance? First let’s touch on a few things that a healthy relationship may possess and then we can look at a few questions in different areas that are similar to what you might hear from a couples therapist if you begin marital counseling or couples therapy.

Here are some of the hallmarks of a healthy relationship according to some couples theorists (Jourard & Landsman, 1980):

1. Good communication
2. Realistic expectations in the relationship and reasonable demands on your partner
3. Genuine concern for the well being of your partner
4. Freedom to be oneself

While some of us may take these four components to be common assumptions, others may struggle with a few of them. At a minimum, even with both partners endorsing the component, partners may disagree about the meaning, or have difficulty successfully executing.

Good Communication

Few clients I have seen in couples therapy have ever said they believe good communication is a bad idea. But the vast majority of couples have at least one partner who believes their partner does not communicate enough, communicates too much, or communicates incorrectly, and often both partners take one of these views. The stereotype that men do not communicate as much about their feelings is something supported by research, and is something I have seen from men in heterosexual and homosexual relationships. With that said, I prefer not to operate with that assumption, as I have seen enough exceptions in couples therapy, in terms of women who do not share and express certain if not all emotions, and some men who are very emotionally expressive. It becomes very obvious in early sessions how comfortable and how able each individual is at identifying their emotions, wishes, desires, frustrations, etc. and how willing and able he/she is to express them to the partner.

One fundamental skill that can be taught as a communication skill in couples therapy is assertiveness. Simply put, assertiveness is comprised of both communicating feelings, thoughts, wishes, wants, desires, and requests in an effective way and accepting the response or lack of response from one’s partner. The second part is often something that is not emphasized enough. But it is critical that each of us learn to accept (that does not mean agree or endorse), i.e., acknowledge whether our request was granted or not, and effectively respond. Specific statements can be learned and certain provocative styles are to be avoided when assertively communicating. But even once these skills are learned, it takes lots of practice to reliably use them. For most of us making requests of others or making ourselves vulnerable by sharing our intimate wishes is an extremely charged experience, and so it takes doing it again and again, even while having emotions to make it a dominant way of communicating.

Expectations and Demands

These are components of a relationship that are highly variable both in partners in a particular couple, and between couples. While each partner doesn’t have to share the same expectations and demands for the other, agreement about what each expects is necessary to make the partnership satisfactory.

Fairness is a theme that comes up a lot in couples therapy, and it often elicits feelings of anger, resentment, and at times guilt. It is rare that two people will have the same strengths, weaknesses, or tendencies. So the division of labor may differ, their capacity to be emotionally intelligent may vary, and one may be more equipped to financially support them both. Fairness then is unlikely to mean each does the same thing for each other, but rather that it is clear and acceptable what each expects and demands from him or herself and the partner.

I have seen many couples where deep resentment exists as a result of an admittedly slight difference in the workload between them. Likewise I have seen perfect harmony achieved when one partner is clearly burdened with the majority of responsibilities in the relationship. What is critical is that each is transparent about what is expected and required and that there is open communication about this, which can include appreciation.

Welfare of others

In couples therapy work, you do find times when the resentment has been growing for so long, or a recent transgression has elicited so much anger that concern may not be something that is readily exhibited. But even in the latter case, when a sincere conversation explores the topic, there is often concern for the general well being of the other (although not always). What I see more often in couples therapy, is a partner who says, “He clearly isn’t concerned about my feelings or well being, or he wouldn’t treat me like this.” This requires both individuals to do some work. And this is not always easy to hear, especially for the person who believes he/she isn’t being cared for. Without question, the couples therapy has to address the behavior that is or isn’t occurring that leads one partner to believe the other doesn’t care. The other piece though, may include both partners as they uncover what attributions are being made about that behavior. For example, one partner may state, “He doesn’t care about me because I tell him how stressed I am about making my work deadlines in order to get my next promotion, yet he is constantly guilt tripping me to leave the office. If he cared about me, he would support me right now, instead he says the very things he knows hurt me.” In a case like this, uncovering what each believes the other’s reasons are for the behavior, i.e., calling her to come home and staying late away from home to complete work, is going to be critical for them to achieve understanding and change the emotional and behavioral pattern in which they have become stuck.

Free to be me

Some of us may find this component to be one that shouldn’t be included in what makes a couple healthy. Isn’t being in a relationship about merging? Shedding our individuality in search of a more meaningful union? In fact, I have treated many couples where one complains that the partner’s very desire to “be him/herself,” is the problem. There is a fine line to walk when it comes to understanding what this freedom constitutes. No matter how open a couple is, clearly some expectations of each partner change when couplehood is undertaken. But what that looks like varies greatly. Does that mean every guys’ night is eclipsed by a date night, or girls’ weekends can never happen because weekends are for family time? Those are questions very much in need of discussion and often times, negotiation.

I have seen people in couples therapy where the presenting problem centers on this issue. One partner doesn’t believe the other has changed enough, or matured enough. “He will never grow up and put away his toys, it is like nothing has changed- there is no growth.” Meanwhile some partners give up activities or relationships that are central to who s/he believes s/he is. This can create resentment or depression- and some times both.

Healthy romantic relationships certainly take on an identity of their own, but it is critical for them to thrive that each partner also has an identify of his/her own, and has time and aspects of his/her life that are his/her own. It is easy to see how frequently there is interplay among the four components of a healthy relationship. To balance this component there needs to be clear communication and negotiation as well as explicit expectations, and an understanding of what it means for each partner to maintain certain aspects of his/her identity or to preserve certain activities or relationships. Depending on what the activities are or who the relationships are with, the decision to maintain these may be more or less acceptable to the partner. But before a lot of communication is required on this topic, self-inventories are a good idea. Each partner really needs to understand what these activities and relationships (e.g., time with friends, coworkers, family, etc.) mean to him or her and how dissatisfied s/he would be without or with less of each.

Once it is clear to each partner how much of a priority each of these are, communicating about what it means to the partner begins the dialogue. Again attributions are crucial to the negotiation process, as it is often what the partner believes it means that is more important than how many guys’ nights occur. Likewise, once it is clear why the freedom bothers the partner, there may be practical tradeoffs that can be made in order to satisfy both parties. Maybe two guys’ nights are acceptable, as long as that partner takes care of breakfast on the weekends.

Couples therapy is a process of identifying areas of dissatisfaction, understanding the function of each problematic behavior, and recognizing what strengths can be built upon, and what behaviors may be missing that can be added. With those targets in mind, it can be an exciting process. Of course, there are many apparent barriers that present themselves- but with careful self-inventories, an understanding of the meanings that are being made, and communication and negotiation many of these can be overcome, and some of those that can’t be, can be accepted, leading to greater personal and relationship satisfaction.

male eating disorder

Male Eating Disorders

Dangers of Beauty

Beautiful people everywhere…what new club or exotic resort destination can boast this tag line? Your kitchen before the second sip of coffee. Whether we are skimming a magazine, surfing the web, or flipping channels, images of thin women and muscular men without much body fat, are likely to bombard our psyches. While the majority of Americans have increased their waist sizes, the aesthetic ideals promoted by swimsuit and organic health shake ads alike are leaner than ever before.

Men and Eating Disorders

Body image issues surrounding our weight or body shape are very common. And there are huge industries bolstered by our obsession with becoming or staying thin, “fighting” aging and becoming more muscular. For decades women in the United States have increasingly suffered with eating disorder symptoms. Younger and younger females are presenting with severe symptoms, and many men and boys are also receiving diagnoses and treatment for eating disorders. Without question, women have suffered in greater numbers from eating disorders than men. Yet it has been important in recent years for treatment providers to begin to recognize the growing need for awareness of the increasing number of men suffering from these issues. In addition to more men developing eating disorders, there are other hurdles for men regarding eating disorders.

Anorexia Nervosa and Men

Many clinicians are not socialized in their training to assess for eating disorder symptoms in men. Even more striking are gender based diagnosis problems like amenorrhea, being listed as a symptom of Anorexia Nervosa. Clearly men are not ever going to lose their menstrual cycles. Not only does this complicate a diagnosis- it skews the way clinicians see potential sufferers. And as we can imagine it shapes how men who suffer may see their own problems- as something not masculine.

Male Shame

Shame and embarrassment accompany many mental health issues, and eating disorders are no exception. But, these distressing emotions may be even more frequent and intense for men suffering from an eating disorder. While the norms have been changing, eating disorders are still not something that many men people admire have admitted to having. Without any cultural models of someone we respect admitting they suffered and recovered, it makes it more difficult for men to come to terms with the problem and get help.

Combined Obstacles to Treatment

So we have a man who is likely confused, ashamed, and embarrassed with his suffering. Men are already at baseline less likely to share feelings or ask for help from a mental health professional, and that makes diagnosis less likely. Even if an accurate diagnosis and the motivation exist, men often still struggle to find treatment providers. There are obvious reasons, but the majority of eating disorder specialists have had much more experience treating women. Likewise many outpatient groups and even residential eating disorder treatment centers are not equipped to treat men.

Causes of Increase in Male Eating Disorder Diagnoses

It is unclear how much of the increase in male eating disorders is about improvements in clinician diagnosis, increased willingness of men to share symptoms, or changes in the culture that have increased the actual prevalence of symptoms. Hopefully professionals will become more attuned to looking for signs and asking men important questions that reduce embarrassment and shame, and eventually build the trust necessary to express the suffering that is a hallmark of eating disorders. While it is unclear what is causative, there does seem to be a correlation between how men have been depicted in magazines and the increase in eating disorders. Men pictured with their shirts off in magazines increased 11 times from the 1950s to the 1990s. It isn’t clear whether these images are causative or reflective, but it is clear that men’s behaviors have certainly changed over time and that has resulted in changes in their physiques and the numbers diagnosed with eating disorders.

Eating Disorder Research

My hope is that Eating Disorder research will continue to get the funding it needs, and that includes evaluating public policy and educational programs. Changes requiring models to be above a Body Mass Index (BMI) in some European countries are an interesting proposal. If these and other policy changes could be implemented long-term and if evaluations of their impact are significant, it could be a feasible method for preventing the development of the number of eating disorders we are seeing now.

Effective Eating Disorder Treatment

Unfortunately, in terms of treatment, Anorexia Nervosa is still very difficult to treat. But it is critical that anyone experiencing symptoms seek treatment. The Maudsley Family Based treatment approach has some of the best results. Although the clinical and research communities have a long way to go, people with an Anorexia Nervosa diagnosis are well advised to engage a professional for treatment. On a more optimistic note, the scientific literature demonstrates that Bulimia Nervosa and Binge Eating Disorder (BED) are very responsive to treatment. Cognitive Behavior Therapy (CBT) has been effective at treating both of these eating disorders. So if anyone believes she/he may be experiencing distress around eating behaviors and body image issues, I strongly encourage them to contact a qualified psychologist, mental health counselor, social worker, or medical professional with experience using empirically supported treatments for eating disorders.

Despite the obstacles for anyone, male or female, suffering with an eating disorder, there are good reasons for optimism. Aside from the good efficacy rates for Bulimia Nervosa and Binge Eating Disorder, more and more clinicians are being sensitized to the problem. This has been reflected in a few residential treatment centers designing programs that are appropriate for men, and societal attention to the impact our overvaluation of beauty may be having on body image and eating behaviors. There are also a number of research labs investigating integrating different treatment modalities in hopes of finding a more effective treatment for Anorexia Nervosa. Dissemination of cognitive behavioral therapies (CBT) and behavioral therapies to greater numbers of clinicians, who in the past may have hesitated from treating patients, or who may have been using techniques that are not helpful. So greater numbers of sufferers should have access to properly trained therapists. The first step is opening up to the possibility that the suffering may be treatable- and then asking for help.