Cognitive Behavior Therapy: REBT, The Elegant Solution
Cognitive Behavioral Therapy (CBT) is a term bandied around a lot in news stories or any conversation about therapy. There is a lot of scientific support for its efficacy in treating issues such as Obsessive Compulsive Disorder (OCD), Post-traumatic Stress Disorder (PTSD), unipolar depression, anger, and bulimia. But there is still not perfect consensus among researchers, theorists, and clinicians about what exactly CBT is and what it isn’t. While some disagreements are about whether or not cognitive changes or learning principles (behavioral) are responsible for someone with depression feeling less depressed, some of the confusion is simply due to the variety of cognitive behavioral treatments.
CBT is often discussed as one monolithic form of therapy, when in fact it is usually used as an umbrella term that includes a variety of different kinds of therapy. Each of these therapies consists of numerous techniques, slightly different models, and different styles or emphases.
Cognitive Behavioral Therapies include therapies like Cognitive Therapy by Aaron T. Beck, Rational Emotive Behavior Therapy (REBT) by Albert Ellis, and Dialectical Behavior Therapy (DBT) by Marsha Linehan. Without question, there are many common elements, but the differences can be critical. For example, the impetus for Dr. Linehan creating DBT was that when she used traditional CBT to treat chronically suicidal and depressed women, CBT made them worse. Therefore, the differences between two kinds of CBT could be critical when working with the population currently classified as having Borderline Personality Disorder (BPD). Other differences may favor particular problems, timing, patient personalities, or the personality of the therapist.
Cognitive Therapy is considered the gold standard for treating depression and has been shown to be effective for treating many anxiety disorders as well as other issues. Its name also results in many using this therapy interchangeably with CBT, another reason for not recognizing a therapy like REBT as a form of CBT. Despite the confusing name, Cognitive Therapy, brings a great deal of structure to each therapy session, solid case formulation, and comprehensive treatment planning that can benefit many clients. It also allows for a great deal of flexibility in treatment. But like any Cognitive Behavior Therapy, many of its advocates emphasize certain kinds of cognitions.
Many forms of CBT propose that mental health problems are largely about two things: unhealthy feelings and maladaptive behaviors. Those two big ticket items are obviously related to other issues like toxic or lacking interpersonal relationships, poor physical health, etc. But most CBT therapists are focusing on helping their clients change feelings and behaviors in ways that will reduce suffering and increase satisfaction with life.
How does a CBT therapist do this?
The simple version proposed by CBT therapists is that we come into contact with stressful events in life (Activating Events), we then have thoughts (Beliefs) about these events, about ourselves, and about the world, that lead to feelings (Consequence-feeling), which set the stage for certain behaviors (Consequence-behavior). This is the A-B-C model.
Here is an example: I am standing at a podium speaking to a bunch of therapists at a CBT conference and I notice a number of them yawning (Activating Event). I then become incredibly uncomfortable and anxious (Consequence-feeling), even sweating from my palms and feeling my heart pound in my chest. The feeling becomes so overwhelming, I begin to stutter, knock over my water glass when I reach for my notes, and end up wrapping up two slides early (Consequence-behavior).
So here we have a stressor (Activating Event), which precedes an intense feeling (Consequence-feeling), which is then followed by behaviors, poor communication and finishing early (Consequence-behavior).
A CBT therapist may ask, me, “If 1,000 people were speaking to that very audience and noticed some people yawning, would they all feel exactly as anxious as you did?” I would likely respond, “Probably not.” The reason I might give is because of some early incident when I was in fourth grade when a bunch of kids teased me and made me feel inadequate and unlikable. But the CBT therapist would ask, “Ok maybe that is when those feelings started, but what were you telling yourself at the podium in that moment that someone who wasn’t anxious wasn’t telling him or herself—that is what is causing your anxiety now?” Activating Event x Belief = Consequences. It is not the event alone, but the combination of the “A” and the “B” that produces the “C.”
For the CBT therapist, it is what we are telling ourselves while the stressor is occurring that is responsible for the anxiety now. It may have started a long time ago, but the best way to change it is to find the current thought (Belief) and change it. By changing the thought, we change the feeling, which makes behaving well a lot easier. When we are anxious it makes it so much tougher to speak calmly, to search for the right word, to fluidly reach over and grab a glass of water and smoothly take a sip before going to the next slide.
What may have caused me to feel like I was about to die? After all the scariest thing in the room was a yawning Ph.D. who probably couldn’t bench press his lunch? It was probably some scary thought like, “Everyone is yawning, they are all bored, I’ll never be asked to speak again at this conference, my career is over, and I’m a failure!”
One approach would be to first identify and even label these kinds of thoughts, i.e.,
• overgeneralization (extending a conclusion from one or a few pieces of data to many more),
• personalization (what others did or said is a poor reflection about me),
• selective abstraction (paying too much attention to the negative and ignoring positive information), and
• dichotomous thinking (I’m either a success or a failure).
Once the therapist and patient identify these thoughts, they can move to challenge them. Here are some questions to challenge these thoughts:
“Is everyone really yawning, or is it really more like five in a room of 300 people, can you calculate the real percentage instead of saying everyone?”
“Ok, even if there are a lot of people yawning, what evidence do you have that they are bored or that you are boring, couldn’t they just be tired because they partied late with colleagues, after all therapists don’t get many opportunities to go out?”
“Even if some people in this audience are bored by your talk, how does that make you a failure, don’t some people find your presentations interesting, so doesn’t that mean you aren’t a failure?”
“Why don’t you tell me why you are still worthwhile, even if some people found some parts of one presentation, at one particular conference boring?”
After those questions I might say, “Even if they think I’m boring, that doesn’t mean everyone does, and even if I’m not very good at giving a talk, I still do a good job teaching and doing therapy, and there are other areas of my life too. I’m good at what I do, so I think I’m a success and still worthwhile, even if I bore some people sometimes!”
This is a fairly standard approach to challenging cognitions that make people anxious.
What’s the problem with this new kind of thinking? I have just recognized that I am not simply a failure because I failed to keep every audience member interested. I even recognize that I have succeeded at many other things too. I’m not simply one thing, but a combination, so I’m still a success. Great new philosophy—right?
Wrong—if I believe that I’m a success because even though I occasionally bore a few people, I still do other things well, how will I feel after I get positive feedback from my students and patients? I would probably feel excited and happy at first, and then I might feel anxious. Why? Because my view of myself as a success is conditional. Even though I have diversified the risk, i.e., I haven’t made my worth or view of myself as a success completely about one thing (giving a particular presentation), it is still dependent on something that could change. So ultimately I know that I could lose my job, I could lose the respect of my students or clients, and so in order to be safe I better work really, really hard in hopes of keeping my positive self-concept, or at any moment, I could become a failure. Doesn’t that sound like a stressful way to live?
How much sense does it make that I am a success because I succeed most of the time? If I win a tennis match at 11:00 am, what does that make me at 11:05 am—a winner? What happens when I lose a match at 1:30 pm—do I become a loser by 1:32 pm? And if I win again at 3:30 pm—putting me back at winning 67% of the time— am I a winner again by 3:34 pm? Does it really make sense that I’m a winner one hour, a loser the next, and then a winner again? How could I be anything but anxious while playing my next tennis match if I know that if I lose I become a loser again—how nerve wracking? If my identity or worth is tied to my performance or what others think of me, I’m in big trouble.
Is there another way? We better hope so, because for most of us, there is a good chance we are going to lose sometimes—even often. And not just respect or the attention span of an audience member or two. We are going to lose jobs, friends, marriages, and all kinds of things. One form of CBT emphasizes a slightly different approach.
REBT is a particular kind of CBT that stresses what it calls “The Elegant Solution.”
In the same public speaking situation, an REBT therapist might encourage me to imagine that my worries are accurate. Instead of having me question if that many people are really yawning or challenging the inference they are yawning because they are bored, in REBT a therapist might have me assume the worst I was imagining. “Imagine it isn’t just a few of them yawning, there are a lot of them, and the audience members aren’t tired from partying late, they are yawning because they are bored while listening to you. While you are at it, many of them are probably bored and they just aren’t yawning.” In REBT, you may acknowledge the very real possibility that many times in life you won’t achieve what you want, or receive the comfort or fairness you desire. But you don’t have to make yourself miserable by believing it can’t be that way or you need to succeed to be ok.
The elegant solution would be to believe that there is nothing that says I have to always deliver presentations that interest every audience member, that it isn’t awful if every single audience member is bored out of his/her head, if that happens I can tolerate it, and no matter how many people I bore to death, I can unconditionally accept myself. Not only does this approach help one deal with the anxiety while noticing audience members are yawning, it helps in the long-term as well. If I believe I’m acceptable and can tolerate failure and being negatively judged by others, then I don’t have to be worried each time I give my next speech. My self-concept, ego, worth, or whatever you want to call it, is no longer on the line each time. I can choose to accept myself independent of my achievements or others’ perceptions of me. This frees me up to take risks and to engage in life.
Now that doesn’t mean it isn’t useful to challenge the traditional cognitive errors like exaggerating how many people are yawning or question my ability to read a person’s mind who is yawning, assuming I know it is because he/she is bored instead of tired. But if I can adopt the elegant solution I can keep my anxiety down and deliver the best presentation I can, regardless of how many people are yawning or are bored. That solution generalizes to so many more situations. After all, I’ll never really know if someone is yawning because they are bored or tired. Even if you ask someone, he/she may politely lie and say it was a late night and an early morning. How elegant to be free from ever having to know?
There are four basic core irrational beliefs to find and dispute if you want to find the elegant solution:
• Demands – I have to always deliver interesting presentations
• Low Frustration Tolerance – I can’t stand disappointing people
• Awfulizing – It is awful if people think I’m inadequate
• Global Evaluations of Worth – I’m a failure if I perform poorly 51% of the time
Once you catch one or more of these kinds of thoughts, you want to challenge or dispute them. You want to cross-examine them as if they are a hostile witness and you are an attorney hell bent on getting the truth.
“Where is the evidence that you have to deliver an interesting presentation every time, isn’t it true that it is possible for you to deliver one that isn’t interesting? I realize you may not want to do that, but isn’t it possible you could?”
“I understand you don’t like disappointing people, but what percentage of the time have you survived disappointing people in your past?”
“It is really unfortunate each time someone judges you as inadequate, but to say it is awful seems like an exaggeration. Can you imagine five things that are worse? If you can, then what word would you use to describe them if you are using “awful” for what someone thinks of you?”
“How does it logically follow that you become a failure if you fail at something, even if you frequently fail? Would you immediately become a success if you succeeded at your next attempt? Does it really make sense that your identity as a success or failure could shift minute to minute?”
If we can begin to catch and challenge these irrational beliefs in these ways, over time, we may begin to internalize the elegant solution. These techniques are one set of skills from REBT that can help each of us to be less upset and to behave in ways that help us live a more satisfying life.