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COGNITIVE METHODS
REBT practitioners usually incorporate a forceful cognitive methodology in the therapeutic process. They demonstrate to clients in a quick and direct manner what it is that they are continuing to tell themselves. Then they teach clients how to deal with these self-statements so that they no longer believe them, encouraging them to acquire a philosophy based on reality. REBT relies heavily on thinking, disputing, debating, challenging, interpreting, explaining, and teaching. The most effi cient way to bring about lasting emotional and behavioral change is for clients to change their way of thinking. Here are some cognitive techniques available to the therapist.
Disputing irrational beliefs. The most common cognitive method of REBT consists of the therapist
actively disputing clients irrational beliefs and teaching them how to do this challenging on their own. Clients go over a particular must, should, or ought until they no longer hold that irrational belief, or at least until it is diminished in strength. Here are some examples of questions or statements clients learn to tell themselves: Why must people treat me fairly? How do I become a total fl op if I dont succeed at important tasks I try? If I dont get the job I want, it may be disappointing, but I can certainly stand it. If life doesnt always go the way I would like it to, it isnt awful, just inconvenient.
Doing cognitive homework. REBT clients are expected to make lists of their problems, look for
their absolutist beliefs, and dispute these beliefs. They often fill out the REBT Self-Help Form, which is reproduced in Coreys (2009b) Student Manual for Theory and Practice of Counseling
and Psychotherapy. They can bring this form to their therapy sessions and critically evaluate the
disputation of some of their beliefs. Homework assignments are a way of tracking down the absolutist shoulds and musts that are part of their internalized selfmessages. Part of this
homework consists of applying the A-B-C model to many of the problems clients encounter in daily life. Work in the therapy session can be designed in such a way that out-of-office tasks are feasible and the client has the skills to complete these tasks. In carrying out homework, clients are encouraged to put themselves in risk taking situations that will allow them to challenge their self-limiting beliefs. For example, a client with a talent for acting who is afraid to act in front of an audience because of fear of failure may be asked to take a small part in a stage play. The client is instructed to replace negative selfstatements such as I will fail, I will look foolish, or No one will like me with more positive messages such as Even if I do behave foolishly at times, this does The theory behind this and similar assignments is that clients often create a negative, self-fulfilling prophecy and actually fail because they told themselves in advance that they would. Clients are encouraged to carry out specific assignments during the sessions and, especially, in everyday situations between sessions. In this way clients gradually learn to deal with anxiety and challenge basic irrational thinking. Because therapy is seen as an educational process, clients are also encouraged to read REBT self-help books, such as How to Be Happy and Remarkably Less Disturbable; Feeling Better,
Getting Better, and Staying Better; and Rational Emotive Behavior Therapy: It Works for MeIt Can Work for You . They also listen to and evaluate tapes of their own therapy sessions. Making
changes is hard work, and doing work outside the sessions is of real value in revising clients thinking, feeling, and behaving.
Changing ones language. REBT contends that imprecise language is one of the causes of
distorted thinking processes. Clients learn that musts, oughts, and shoulds can be replaced by preferences. Instead of saying It would be absolutely awful if . . ., they learn to say It would be inconvenient if . . .. Clients who use language patterns that refl ect helplessness and self-condemnation can learn to employ new self-statements, which help them think and behave differently. As a consequence, they also begin to feel differently.
Psychoeducational methods. REBT and most other cognitive behavior therapy programs introduce
clients to various educational materials. Therapists educate clients about the nature of their problems and how treatment is likely to proceed. They ask clients how particular concepts apply to them. Clients are more likely to cooperate with a treatment program if they understand how the therapy process works and if they understand why particular techniques are being used.
EMOTIVE TECHNIQUES
REBT practitioners use a variety of emotive procedures, including unconditional acceptance, rational emotive role playing, modelling, rational emotive imagery, and shame-attacking exercises. Clients are taught the value of unconditional self-acceptance. Even though their behaviour may be difficult to accept,
they can decide to see themselves as worthwhile persons. Clients are taught how destructive it is to engage in putting oneself down for perceived deficiencies. REBT employs a variety of emotive techniques, which tend to be vivid and evocative in nature, the main purpose is to dispute clients irrational beliefs. These strategies are used both during the therapy sessions and as homework assignments in daily life. Their purpose is not simply to provide a cathartic experience but to help clients change some of their thoughts, emotions, and behaviors. Lets look at some of these evocative and emotive therapeutic techniques in more detail.
Rational emotive imagery. This technique is a form of intense mental practice designed to
establish new emotional patterns. Clients imagine themselves thinking, feeling, and behaving exactly the way they would like to think, feel, and behave in real life. They can also be shown how to imagine one of the worst things that could happen to them, how to feel unhealthily upset about this situation, how to intensely experience their feelings, and then how to change the experience to a healthy negative feeling. As clients change their feelings about adversities, they stand a better chance of changing their behavior in the situation. Such a technique can be usefully applied to interpersonal and other situations that are problematic for the individual. Ellis maintains that if we keep practicing rational emotive imagery several times a week for a few weeks, we can reach the point that we no longer feel upset over negative events.
Using humor. REBT contends that emotional disturbances often result from taking oneself too
seriously. One appealing aspects of REBT is that it fosters the development of a better sense of humor and helps put life into perspective. Humor has both cognitive and emotional benefi ts in bringing about change. Humor shows the absurdity of certain ideas that clients steadfastly maintain, and it can be of value in helping clients take themselves much less seriously. Ellis himself tends to use a good deal of humor to combat exaggerated thinking that leads clients into trouble. In his workshops and therapy sessions, Ellis typically uses humorous songs, and he encourages people to sing to themselves or in groups when they feel depressed or anxious. His style of presenting is humorous and he seems to enjoy using words like horseshit!
Role playing. Role playing has emotive, cognitive, and behavioral components, and the therapist
often interrupts to show clients what they are telling themselves to create their disturbances and what they can do to change their unhealthy feelings to healthy ones. Clients can rehearse certain behaviors to bring out what they feel in a situation. The focus is on working through the underlying irrational beliefs that are related to unpleasant feelings. For example, Dawson may put off applying to a graduate school because of his fears of not being accepted. Just the thought of not being accepted to the school of his choice brings out intense feelings of being stupid. Dawson role-plays an interview with the dean of graduate students, notes his anxiety and the specific beliefs leading to it, and challenges his conviction that he absolutely must be accepted and that not gaining such acceptance means that he is a stupid and incompetent person.
Shame-attacking exercises. Ellis developed exercises to help people reduce shame over behaving
in certain ways. He thinks that we can stubbornly refuse to feel ashamed by telling ourselves that it is not catastrophic if someone thinks we are foolish. The main point of these exercises, which typically involve both emotive and behavioral components, is that clients work to feel unashamed even when others clearly disapprove of them. The exercises are aimed at increasing selfacceptance and mature responsibility, as well as helping clients see that much of what they think of as being shameful has to do with the way they define reality for themselves. Clients may accept a homework assignment to take the risk of doing something that they are ordinarily afraid to do because of what others might think. Minor infractions of social conventions often serve as useful catalysts. For example, clients may shout out the stops on a bus or a train, wear loud clothes designed to attract attention, sing at the top of their lungs, ask a silly question at a lecture, or ask for a left-handed monkey wrench in a grocery store. By carrying out such assignments, clients are likely to find out that other people are not really that interested in their behavior. They work on themselves so that they do not feel ashamed or humiliated, even when they acknowledge that some of their acts will lead to judgments by others. They continue practicing these exercises until they realize that their feelings of shame are self-created and until they are able to behave in less inhibited ways. Clients eventually learn that they often have no reason for continuing to let others reactions or possible disapproval stop them from doing the things they would like to do. Note that these exercises do not involve illegal activities or acts that will be harmful to oneself or to others.
Use of force and vigor. Ellis has suggested the use of force and energy as a way to help clients
go from intellectual to emotional insight. Clients are also shown how to conduct forceful dialogues with themselves in which they express their unsubstantiated beliefs and then powerfully dispute them. Sometimes the therapist will engage in reverse role playing by strongly clinging to the clients self-defeating philosophy. Then, the client is asked to vigorously debate with the therapist in an attempt to persuade him or her to give up these dysfunctional ideas. Force and energy are a basic part of shame-attacking exercises.
BEHAVIORAL TECHNIQUES
REBT practitioners use most of the standard behaviour therapy procedures, especially operant conditioning, self-management principles, systematic desensitization, relaxation techniques, and modeling. Behavioral homework assignments to be carried out in real-life situations are particularly important. These assignments are done systematically and are recorded and analyzed on a form. Homework gives clients opportunities to practice new skills outside of the therapy session, which may be even more valuable for clients than work done during the therapy hour. Doing homework may involve desensitization and live exposure in daily life situations. Clients can be encouraged to desensitize
themselves gradually but also, at times, to perform the very things they dread doing implosively. For example, a person with a fear of elevators may decrease this fear by going up and down in an elevator 20 or 30 times in a day. Clients actually do new and difficult things, and in this way they put their insights to use in the form of concrete action. By acting differently, they also tend to incorporate functional beliefs.
RESEARCH EFFORTS
If a particular technique does not seem to be producing results, the REBT therapist is likely to switch to another. This therapeutic flexibility makes controlled research difficult. As enthusiastic as he is about cognitive behavior therapy, Ellis admits that practically all therapy outcome studies are flawed. According to him, these studies mainly test how people feel better but not how they have made a profound philosophical-behavioral change and thereby get better. Most studies focus only on cognitive methods and do not consider emotive and behavioral methods, yet the studies would be improved if they focused on all three REBT methods.
to 10 sessions and then practiced at home. Ellis has used REBT successfully in 1- and 2-day marathons and in 9-hour REBT intensives. People with specific problems, such as coping with the loss of a job or dealing with retirement, are taught how to apply REBT principles to treat themselves, often with supplementary didactic materials (books, tapes, self-help forms, and the like).
Beck contends that people with emotional difficulties tend to commit characteristic logical errors that tilt objective reality in the direction of self-deprecation. Lets examine some of the systematic errors in reasoning that lead to faulty assumptions and misconceptions, which are termed cognitive distortions.
Arbitrary inferences refer to making conclusions without supporting and relevant evidence. This
includes catastrophizing, or thinking of the absolute worst scenario and outcomes for most situations. You might begin your first job as a counselor with the conviction that you will not be liked or valued by either your colleagues or your clients. You are convinced that you fooled your professors and somehow just managed to get your degree, but now people will certainly see through you!
Overgeneralization is a process of holding extreme beliefs on the basis of a single incident and
applying them inappropriately to dissimilar events or settings. If you have difficulty working with one adolescent, for example, you might conclude that you will not be effective counseling any adolescents. You might also conclude that you will not be effective working with any clients!
Magnification and minimization consist of perceiving a case or situation in a greater or lesser light
than it truly deserves. You might make this cognitive error by assuming that even minor mistakes in counseling a client could easily create a crisis for the individual and might result in psychological damage.
Personalization is a tendency for individuals to relate external events to themselves, even when
there is no basis for making this connection. If a client does not return for a second counseling session, you might be absolutely convinced that this absence is due to your terrible performance during the initial session. You might tell yourself, This situation proves that I really let that client down, and now she may never seek help again.
Labeling and mislabeling involve portraying ones identity on the basis of imperfections and
mistakes made in the past and allowing them to defi ne ones true identity. Thus, if you are not able to live up to all of a clients expectations, you might say to yourself, Im totally worthless and should turn my professional license in right away.
The cognitive therapist operates on the assumption that the most direct way to change dysfunctional emotions and behaviors is to modify inaccurate and dysfunctional thinking. The cognitive therapist teaches clients how to identify these distorted and dysfunctional cognitions through a process of evaluation. Through a collaborative effort, clients learn the influence that cognition has on their feelings and behaviors and even on environmental events. In cognitive therapy, clients learn to engage in more realistic thinking, especially if they consistently notice times when they tend to get caught up in catastrophic thinking. After they have gained insight into how their unrealistically negative thoughts are affecting them, clients are trained to test these automatic thoughts against reality by examining and weighing the evidence for and against them. They can begin to monitor the frequency with which these beliefs intrude in situations in everyday life. The frequently asked question is, Where is the evidence for _____? If this question is raised often enough, clients are likely to make it a practice to ask themselves this question, especially as they become more adept at identifying dysfunctional thoughts. This process of critically examining their core beliefs involves empirically testing them by actively engaging in a Socratic dialogue with the therapist, carrying out homework assignments, gathering data on assumptions they make, keeping a record of activities, and forming alternative. Clients form hypotheses about their behavior and eventually learn to employ specific problem-solving and coping skills. Through a process of guided discovery, clients acquire insight about the connection between their thinking and the ways they act and feel. Cognitive therapy is focused on present problems, regardless of a clients diagnosis. The past may be brought into therapy when the therapist considers it essential to understand how and when certain core dysfunctional beliefs originated and how these ideas have a current impact on the clients specifi c schema. The goals of this brief therapy include providing symptom relief, assisting clients in resolving their most pressing problems, and teaching clients relapse prevention strategies. More recently, increasing attention has been placed on the unconscious, the emotional dimensions, and even existential components of CT treatment.
more emphasis on helping clients discover and identify their misconceptions for themselves than does REBT. Through this reflective questioning process, the cognitive therapist attempts to collaborate with clients in testing the validity of their cognitions (a process termed collaborative empiricism). Therapeutic change is the result of clients confronting faulty beliefs with contradictory evidence that they have gathered and evaluated. There are also differences in how Ellis and Beck view faulty thinking. Through a process of rational disputation, Ellis works to persuade clients that certain of their beliefs are irrational and nonfunctional. Beck (1976) takes exception to REBTs concept of irrational beliefs. Cognitive therapists view dysfunctional beliefs as being problematic because they interfere with normal cognitive processing, not because they are irrational. Instead of irrational beliefs, Beck maintains that some ideas are too absolute, broad, and extreme. For him, people live by rules (premises or formulas); they get into trouble when they label, interpret, and evaluate by a set of rules that are unrealistic or when they use the rules inappropriately or excessively. If clients make the determination that they are living by rules that are likely to lead to misery, the therapist may suggest alternative rules for them to consider, without indoctrinating them. Although cognitive therapy often begins by recognizing the clients frame of reference, the therapist continues to ask for evidence for a belief system.
participation and collaboration throughout all phases of therapy, including deciding how often to meet, how long therapy should last, what problems to explore, and setting an agenda for each therapy session. Beck conceptualizes a partnership to devise personally meaningful evaluations of the clients negative assumptions, as opposed to the therapist directly suggesting alternative cognitions. The therapist functions as a catalyst and a guide who helps clients understand how their beliefs and attitudes influence the way they feel and act. Clients are expected to identify the distortions in their thinking, summarize important points in the session, and collaboratively devise homework assignments that they agree to carry out. Cognitive therapists emphasize the clients role in self-discovery. The assumption is that lasting changes in the clients thinking and behavior will be most likely to occur with the clients initiative, understanding, awareness, and effort. Cognitive therapists aim to teach clients how to be their own therapist. Typically, a therapist will educate clients about the nature and course of their problem, about the process of cognitive therapy, and how thoughts influence their emotions and behaviors. The educative process includes providing clients with information about their presenting problems and about relapse prevention. One way of educating clients is through bibliotherapy, in which clients complete readings dealing with the philosophy of cognitive therapy. According to Dattilio and Freeman (1992, 2007), these readings are assigned as an adjunct to therapy and are designed to enhance the therapeutic process by providing an educational focus. Some popular books often recommended are Love Is Never Enough (Beck, 1988); Feeling Good (Burns, 1988); The Feeling Good Handbook (Burns, 1989); Woulda, Coulda, Shoulda (Freeman & DeWolf, 1990); Mind Over Mood (Greenberger & Padesky, 1995); and The Worry Cure (Leahy, 2005). Cognitive therapy has become known to the general public through self-help books such as these. Homework is often used as a part of cognitive therapy. The homework is tailored to the clients specifi c problem and arises out of the collaborative therapeutic relationship. Tompkins (2004, 2006) outlines the key steps to successful homework assignments and the steps involved in collaboratively designing homework. The purpose of homework is not merely to teach clients new skills but also to enable them to test their beliefs in daily-life situations. Homework is generally presented to clients as an experiment, which increases the openness of clients to get involved in an assignment. Emphasis is placed on self-help assignments that serve as a continuation of issues addressed in a therapy session. Cognitive therapists realize that clients are more likely to complete homework if it is tailored to their needs, if they participate in designing the homework, if they begin the homework in the therapy session, and if they talk about potential problems in implementing the homework. Tompkins (2006) points out that there are clear advantages to the therapist and the client working in a collaborative manner in negotiating mutually agreeable homework tasks. He believes that one of the best indicators of a working alliance is whether homework is done and done well. Tompkins writes: Successful negotiations can strengthen the therapeutic alliance and thereby foster greater motivation to try this and future homework assignments (p. 63)
APPLYING COGNITIVE TECHNIQUES Beck and Weishaar (2008) describe both cognitive and
behavioral techniques that are part of the overall strategies used by cognitive therapists. Techniques are aimed mainly at correcting errors in information processing and modifying core beliefs that result in faulty conclusions. Cognitive techniques focus on identifying and examining a clients beliefs, exploring the origins of these beliefs, and modifying them if the client cannot support these beliefs. Examples of behavioral techniques typically used by cognitive therapists include skills training, role playing, behavioral rehearsal, and exposure therapy. Regardless of the nature of the specifi c problem, the cognitive therapist is mainly interested in applying procedures that will assist individuals in making alternative interpretations of events in their daily living. Think about how you might apply the principles of CT to yourself in this classroom situation and change your feelings surrounding the situation:
Your professor does not call on you during a particular class session. You feel depressed. Cognitively, you are telling yourself: My professor thinks Im stupid class. Furthermore, been this way most of my life! and that I really dont have much of value to offer the shes right, because everyone else is brighter and more articulate than I am. Its
Some possible alternative interpretations are that the professor wants to include others in the discussion, that she is short on time and wants to move ahead, that she already knows your views, or that you are self-conscious about being singled out or called on. The therapist would have you become aware of the distortions in your thinking patterns by examining your automatic thoughts. The therapist would ask you to look at your inferences, which may
be faulty, and then trace them back to earlier experiences in your life. Then the therapist would help you see how you sometimes come to a conclusion (your decision that you are stupid, with little of value to offer) when evidence for such a conclusion is either lacking or based on distorted information from the past. As a client in cognitive therapy, you would also learn about the process of magnification or minimization of thinking, which involves either exaggerating the meaning of an event (you believe the professor thinks you are stupid because she did not acknowledge you on this one occasion) or minimizing it (you belittle your value as a student in the class). The therapist would assist you in learning how you disregard important aspects of a situation, engage in overly simplified and rigid thinking, and generalize from a single incident of failure. Can you think of other situations where you could apply CT procedures?
TREATMENT OF DEPRESSION
Beck challenged the notion that depression results from anger turned inward. Instead, he focuses on the content of the depressives negative thinking and biased interpretation of events. In an earlier study that provided much of the backbone of his theory, Beck (1963) even found cognitive errors in the dream content of depressed clients. Beck (1987) writes about the cognitive triad as a pattern that triggers depression. In the fi rst component of the triad, clients hold a negative view of themselves. They blame their setbacks on personal inadequacies without considering circumstantial explanations. They are convinced that they lack the qualities essential to bring them happiness. The second component of the triad consists of the tendency to interpret experiences in a negative manner. It almost seems as if depressed people select certain facts that conform to their negative conclusions, a process referred to as selective abstraction by Beck. Selective abstraction is used to bolster the individuals negative schema, giving further credence to core beliefs. The third component of the triad pertains to depressed clients gloomy vision and projections about the future. They expect their present difficulties to continue, and they anticipate only failure in the future. Depression-prone people often set rigid, perfectionist goals for themselves that are impossible to attain. Their negative expectations are so strong that even if they experience success in specific tasks they anticipate failure the next time. They screen out successful experiences that are not consistent with their negative self-concept. The thought content of depressed individuals centers on a sense of irreversible loss that results in emotional states of sadness, disappointment, and apathy. Becks therapeutic approach to treating depressed clients focuses on specific problem areas and the reasons clients give for their symptoms. Some of the behavioral symptoms of depression are inactivity, withdrawal, and avoidance. To assess the depth of depression, Beck (1967) designed a standardized device known as the Beck Depression Inventory (BDI). The therapist is likely to probe with Socratic questioning such as this: What would be lost by trying? Will you feel worse if you are passive?
How do you know that it is pointless to try? Therapy procedures include setting up an activity schedule with graded tasks to be completed. Clients are asked to complete easy tasks fi rst, so that they will meet with some success and become slightly more optimistic. The point is to enlist the clients cooperation with the therapist on the assumption that doing something is more likely to lead to feeling better than doing
nothing.
Some depressed clients may harbor suicidal wishes. Cognitive therapy strategies may include exposing the clients ambivalence, generating alternatives, and reducing problems to manageable proportions. For example, the therapist may ask the client to list the reasons for living and for dying. Further, if the client can develop alternative views of a problem, alternative courses of action can be developed. This can result not only in a client feeling better but also behaving in more effective ways. A central characteristic of most depressive people is self-criticism. Underneath the persons selfhate are attitudes of weakness, inadequacy, and lack of responsibility. A number of therapeutic strategies can be used. Clients can be asked to identify and provide reasons for their excessively self-critical behavior. The therapist may ask the client, If I were to make a mistake the way you do, would you despise me as much as you do yourself? A skilful therapist may play the role of the depressed client, portraying the client as inadequate, inept, and weak. This technique can be effective in demonstrating the clients cognitive distortions and arbitrary inferences. The therapist can then discuss with the client how the tyranny of shoulds can lead to self-hate and depression. Depressed clients typically experience painful emotions. They may say that they cannot stand the pain or that nothing can make them feel better. One procedure to counteract painful affect is humor. A therapist can demonstrate the ironic aspects of a situation. If clients can even briefl y experience some lightheartedness, it can serve as an antidote to their sadness. Such a shift in their cognitive set is simply not compatible with their self-critical attitude. Another specific characteristic of depressed people is an exaggeration of external demands, problems, and pressures. Such people often exclaim that they feel overwhelmed and that there is so much to accomplish that they can never do it. A cognitive therapist might ask clients to list things that need to be done, set priorities, check off tasks that have been accomplished, and break down an external problem into manageable units. When problems are discussed, clients often become aware of how they are magnifying the importance of these difficulties. Through rational exploration, clients are able to regain a perspective on defining and accomplishing tasks. The therapist typically has to take the lead in helping clients make a list of their responsibilities, set priorities, and develop a realistic plan of action. Because carrying out such a plan is often inhibited by self-defeating thoughts, it is well for therapists to use cognitive rehearsal techniques in both identifying and changing negative thoughts. If clients can learn to combat their self-doubts in the therapy session, they may be able to apply their newly acquired cognitive and behavioral skills in real-life situations.