Rational Emotive Behavior Therapy (REBT)
and Psychological Adjustment after Bariatric Surgery
Published in Obesity Health
by Daniel J. Moran, Ph.D., BCBA & J. Ryan Fuller, Ph.D.
Let’s say someone is having a difficult time adjusting to their new post-bariatric surgery lifestyle. Perhaps they are depressed or angry about their dietary restrictions. Maybe they are anxious because they had a bout of “dumping” and feel like a failure. These feelings of depression, anger, anxiety, and low self-esteem can lead to unhealthy behaviors. Someone dealing with depression might stop eating healthy altogether and begin to have a negative relationship with food. An angry person may lash out at his or her support group of loved ones. Feeling like a failure may influence further poor eating, and lead to a “relapse.”
One way to intervene with these concerns is to teach the patient that it is not the dietary restrictions that cause depression or anger, nor is it the bout of “dumping” that leads to anxiety and feelings of failure. Cognitive-behavior therapists would suggest that it is the way the person is thinking about those challenges that leads to emotional and behavioral challenges. Rational Emotive Behavioral Therapy (REBT) is a type of cognitive-behavior therapy (CBT) that may be particularly well suited for post-bariatric lifestyle challenges. REBT focuses on emotional management and behavior modification while using a psychoeducational approach to help people think and behave more functionally. It has a simple conceptual model to use with clients and can rely on as few or as many techniques to help the client as appropriate.
REBT was developed by Albert Ellis, and the theory and practice is largely based on the idea that the events that happen to us do not always exclusively determine how we feel. Rather it is often the combination of what we think about what happens that determines how we feel. This philosophy is not new, as we hear Shakespeare’s Hamlet say: “…there is nothing either good or bad but thinking makes it so.” (Act II, Scene II), but Dr. Ellis’s application of this principal was pioneering. His conceptualization of human disturbance is referred to as the ABCDE model. Activating events (A) are any internal (memories, thoughts, feelings) or external (situations, frustrations, personal or others’ behavior) occurrences that precede an emotional episode. Beliefs (B) are our thoughts about those events, ourselves, our skills, our lives, the future, and the world. The products of A’s and B’s are Consequences (C). Emotional Consequences relate to Behavioral Consequences. For instance, the severe dietary restriction is an external Activating event, and the thought, “I hate this diet,” may be an internal Activating event. As a result, the patient may then say something to his or herself such as “I shouldn’t have to keep such an awful diet.” REBT would label that type of self-talk, an irrational belief. Now ask yourself: What would be the Emotional and Behavioral Consequences of that Belief? Perhaps the person would be angry or depressed because they shouldn’t have to eat such an awful diet, and might even dysfunctionally jazz up their food intake with prohibited foods, or take their anger out on a loved one.
REBT suggests that the critical part of therapy is helping people change their irrational Beliefs to rational Beliefs. There are four categories of irrational Beliefs. Demandingness is an irrational belief where a person assumes that their world absolutely must or should conform to their preferences. Not only is this irrational, but entirely unfounded and unhelpful. Awfulizing is when a client will make a mountain out of a molehill. The client magnifies their diet restriction or dumping experience as “awful” or “the worst thing ever.” This is also unsupported by their experience (it’s not really the worst thing that could happen to them) and not a bit helpful to think this way. Low Frustration Tolerance occurs when someone says “I can’t stand this!” In reality, the person may have “been standing” their diet for a few weeks. There is no evidence that someone “can’t stand” a post-surgery diet or can’t tolerate a dumping experience. This is irrational thinking and entirely unhelpful. The final core belief is Global Evaluating, which occurs when someone rates their life, world, self, or someone else in an extreme manner. This is evident when someone says “I am a total failure.” Again, this is not only untrue, but unhelpful. Failing at something does not make a person a total failure.
So in the ABC model, if the diet restriction is the person’s A, imagine that person’s B as either “My diet shouldn’t be like this,” “This is awful,” or “I can’t stand this diet.” The REBT counselor would be vigilant for these types of thoughts as they are likely to influence negative emotional Consequences. These Beliefs might actually thwart positive progress and healthy behavior. If the person believed “I am a total failure” after a dumping Activating event, that too would lead to unhealthy Consequences.
This is where the D comes into the ABCDE picture. REBT therapists help the person Dispute their irrational thoughts. The four aforementioned thought patterns are quite flawed and lead to dysfunctional, undervalued Consequences, and it is the job of the therapist to help the client gain a new perspective.
There are four different approaches to disputation: Logical, Empirical, Functional, and Behavioral. The Logical approach appeals to the client’s sense of reason. When a client says “I regained a lot of weight this month, therefore I’m a failure,” the therapist may ask how the person came to that conclusion. The Disputation might playfully but pointedly cajole the patient with questions such as, “How is that even a logical thought? Yes, you regained weight (a true premise), but how does it logically follow that you become a total failure from your behavior last month?”
An Empirical Dispute asks for verification of the truth of the thought, and can also be effective. When a client says “I can’t stand this diet,” a therapist may help Dispute by asking, “Haven’t you been standing it for the last few weeks? That seems proof to me that you can stand it! If you could tell yourself anything, why believe that you can’t do something?”
REBT can draw on a vast literature of life-affirming quotes and philosophies, and one that would be apropos with Functional Disputes can be discussing Henry Ford’s famous phrase “If you think you can do a thing or think you can’t, you’re right!” Functional disputes emphasize pragmatics. A patient begins putting herself down for eating off her planned diet. She thinks, “I’m a lazy incapable slob,” and becomes depressed or thinks, “I’m out of control and will never be able to stick to it,” and becomes anxious. A functional intervention would be, “Does repeating these thoughts produce the emotions and behaviors that help you stay on your plan or do they influence you to binge out of control?”
Behavioral Disputes are acts that defy irrational beliefs. A patient may report, “I can’t stand watching thin people eat whatever they want.” Taking three 30 minute trips to the ice cream parlor to watch “thin people” eat hot fudge sundaes will challenge the irrational thought and prove the rational. In this case it supports the rational belief, “It is unpleasant to sip diet soda while others indulge, but I can stand it.”
The idea behind all of these Disputations is to get the client to develop a habit of thinking about the Activating events in their lives. A new pattern of thinking and Believing will lead to Effective Emotions and Behaviors, and may start to generalize to other Activating events, such as when they deal with the frustrations of shopping for new clothes, dealing with strangers’ catcalls, or the frequent interpersonal difficulties that happen during post-surgery life. This transformation may not be easy, but it is as simple as ABCDE.