Learning to Perceive Differently with Rational Emotive Behavior Therapy: An Ethical and Professional Approach to Changing Client’s Neurotic Disturbances.”
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Author: Dr. Murat Artiran
Introduction
Mood disorders are among the top 10 causes of worldwide disability, top among which is major depressive disorder (MDD) that is reported to be the first cause of disability worldwide, and accounts for 20-35% of all deaths by suicide. (Szentagotai and David, p. 523). There are a wide variety of symptoms of depression and other mood disorders, and a corresponding variety of therapies available. Many researchers are hard at work trying to find the most effective therapies. The go-to treatment for MDD has for some years been cognitive therapy (CT) and pharmacotherapy. (Szentagotai and David, p.523). However, in reviewing the literature in preparation for the study, Szentagotai and David found that 30-40% of the patients undergoing this type of treatment remained non-responsive to it. (Szentagotai and David, p.524) The researchers set out to test the effectiveness of rational emotive therapy (REBT) instead, with the findings that REBT was more affective at a 6 months post-test than pharmacotherapy, according to the Hamilton Rating Scale for Depression. (p. 525). This suggests that REBT is not only a strong contender for being one more effective therapy in alleviating mood disorders, but is also possibly more effective than some of the more traditional treatment methods.
Rational Emotive Behavior Therapy (REBT) is a part of the group of cognitive behavior therapies, and is based on the premise that most emotional and behavioral disturbances are due to irrational beliefs that an individual holds, which causes him or her to interpret events in a way that is not consistent with reality. (Szentagotai and David, p. 525) The theory defines two main categories of irrational thinking that can cause problems. One is low frustration tolerance, where an individual’s thinking leads him or her to believe that having to deal with circumstances which are not exactly as the individual desires them to be is absolutely intolerable. The second, is low self-worth. (Harrington, pp. 699-700) Szentagotai and David, employing a newer model of REBT, note that these two categories can also be broken down to four subcategories of irrational beliefs: demandingness, awfulizing/catastrophizing, low frustration tolerance, and global evaluation/self-downing. (p. 525) According to the REBT theory, most psychological disturbances can be traced back to one of these modes or irrational thinking. Harrington gives an example of depressed mood as related to a sense of worthlessness, or a belief that life is intolerably difficult. However, most studies show that different irrational beliefs are associated with specific anxiety problems. For instance, anger, seems to be caused by low self-worth, though Harrington suggests the possibility of anger being caused by a threatened high self-esteem, which would put frustration intolerance as its root cause.
Thus, the goal of REBT is for the patient to achieve a different, more philosophical outlook on life, where he or she stops to think in absolute terms, and allows reality to take place without having a strong averse reaction to it. (Engels, Garnefski, and Diekstra, p. 1083) Another major difference between REBT and other cognitive behavior therapies is that REBT only uses behavior modification techniques after the patient has achieved this new way of thinking.
Notably, REBT has been shown to be effective even with such hard-to-tackle problems as obesity (Block, 1980). In the study of obesity, overeating was chosen to test the effectiveness of REBT specifically for the reason that overeating is one of the most resistant of maladaptive habit patterns, often resistant to other forms of therapy. (Block, p. 277) The study found that over-weight REBT recipients underwent a significant weight loss during treatment, and were able to maintain it, and continue to lose weight over an expended follow-up period. (Block, p. 279).
This brings out an interesting aspect of REBT, where studies often show that both positive and negative self-evaluation can be dysfunctional, and a self-perception based in reality is rather much more important. (Harrington, p. 700) The results of a meta analysis of studies measuring positive affect (PA), conducted by Pressman and Cohen (2005) suggest a similar conclusion. The researchers reported on a several studies that found that in regard to older individuals, those who resided in communities, as opposed to institutions, those with greater PA displayed lower mortality rates. However, institutionalized older individuals displaced opposite results, with greater PA associated with higher mortality rates. (Pressman and Cohen, p. 930) These findings were also consistent with a study that reported that higher PA in gifted children was also associated with higher adult mortality rates. The authors suggest that both previous research and common sense lead to the conclusion that happy, healthy individuals, who are optimistic and cheerful, may perceive themselves as less vulnerable to negative health outcomes. (Pressman and Cohen, p. 931)
In general the studies reviewed in the meta-analysis suggest a pattern – healthy and mildly ill individuals are more likely to benefit from higher levels of PA, while terminally ill individuals, or those with a life-threatening disease, with higher PA levels have higher mortality rates than those with moderate or low PA. The authors suggest the possibility that reporting higher levels of PA when dealing with a life-threatening disease is a sign of maladaptive coping, or irrational thinking, as REBT theory would suggest. Another possibility, however, is that those with higher PA may have higher mortality because of choosing to refuse medical treatments and instead live out the rest of their lives in the most normal way possible, without added suffering and stress of treating a serious illness. (Pressman and Cohen, p.935)
Some of the major criticisms of REBT are that the theory and the positive effects of the therapy are only supported by preliminary, un-replicated findings, and that the often therapy works as well as other treatments. (Engels, Garnefski, and Diekstra, p. 1083) Also, being one of the therapies in the family of cognitive-behavior therapies, REBT is often studied as part of the group of these therapies, and therefore, it is unclear how much REBT in particular contributes to the outcome. This may be due, in most cases, as Engels, Garnefski and Diekstra report, due to the fact that most studies do not allow sufficient time for REBT. (p. 1085) The studies reviewed allowed anywhere from 9.2 to 13.5 hours, or 6.7 to 8.4 weeks for REBT to have an effect. (p. 1085) Common sense suggests, however, that a therapy that is aimed at changing the way one thinks, however, needs to be allowed sufficient time to take effect. Another important conclusion the researchers were able to draw from the study is that the effects of REBT in all analyzed studies seemed to be directly related to the increase in rational thinking as a direct result of treatment. (p. 1087)
Method
The effectiveness of REBT is often measured using scales for measuring depressive symptoms, or any other issues for which the therapy is provided before and after administering therapy. Some of the scales used in the studies discussed in this literature review were: Odebunmi (1991) Anxiety, Depression and Stress scales, Frustration Discomfort Scale (FDS), Beck Depression Inventory, Hamilton Rating Scale for Depression, and the Belief Scale (Boelen and Baars, 2007).
The studies dealing with learning and cognition in human psychology employed randomized controlled trials to establish the relationship between the stimuli and the participants’ perception of these stimuli.
Self-reports are very important in assessing the success of REBT, as self-perception together with the patient’s view of reality and its events is what is addressed during REBT, and were often employed for these studies in the form of interviews and surveys.
Finally, some studies performed meta-analyses of various previous studies in order to obtain a more general picture of different therapies and patients’ perceptions (Engels, et. al., 1993, Gonzalez, et. al., 2004, and Simms, et. al., 2012).
Discussion
Rational thinking, which is a central issue in REBT is largely dependent on one’s development, and the way he or she learns to think from parents, peers, and other social interactions. REBT has been generally found to be quite effective with changing dysfunctional thinking patterns in adults, however, a similar benefit is suggested by a 2004 meta-analysis study conduced on the effects of REBT on children and adolescents by Gonzalez, Nelson, Gutkin, Saunders, Galloway and Shwery. The researchers found that though REBT was effective with children and adolescents of all ages, the greatest effect was on elementary school children, whose thinking is the easiest to shape and re-adjust. (p.232) Also, not surprisingly, the study showed that REBT among all age levels was most effective in the medium to highest duration range. (p.232) The effect of REBT on children and adolescents is directly related to the original REBT theory, developed by Ellis in the 1950s and 60s, which maintained that irrational and neurotic early learning persisted in human memory, rather than becoming extinguished if not reinforced. (Adomeh, p. 21) Adomeh (2006) also found that REBT was effective in reducing the levels of anxiety and stress in Nigerian adolescents, more so than other forms of therapy.
The importance of the change in client’s thinking as a result of REBT is illustrated by the studies of positive affect, as related to health. Again, it is important to mention the study by Pressman and Cohen (2005), which found that positive affect was directly related to better health (p. 932), greater recovery rates (p. 935), and more favorable self-evaluations of health (p. 939) in healthy and mildly ill individuals. These findings suggest that a more positive outlook that REBT contributes to may be very beneficial to an individual’s health on many levels. It is also important to note that the same study found that positive affect had a negative influence on health outcomes for terminally ill individuals, and institutionalized older adults, suggesting once again that the emphasis on rational thinking that REBT provides is very beneficial. The researchers suggest that the negative effect of positive thinking in ill individuals is most likely due to the irrational belief that they are less affected by ill health than others, leading these individuals to take less care of themselves. It is easy to see here how thinking more realistically can have a great positive effect on these individuals’ health.
These findings are also supported by a study examining the role of therapist-guided exposure in situ with panic disorder with agoraphobia patients. (Gloster, Helbig-Lang, Hamm, Richter, Gerlach, Kircher, Zwanger, Lang, Fydrich, Fehm, Alpers, Strohle, Deckert, and Hofler, 2011). The researchers found that after participating in cognitive-behavior therapy (CBT), those patients who were also provided therapist-guided exposure in situ to address their agoraphobia and panic attacks displayed greater improvements than those who were not provided with therapist-guided exposure. These findings address an important aspect of CBT – the fact that it appears that the new behaviors, learned during therapy, are not sufficient to replace the old behaviors, such as avoidance behaviors in agoraphobia. (p.417) As a result, when no therapist was present, the patients were more likely to return to their old avoidance behaviors. This is another piece of evidence in support of REBT’s potential superiority in treating such disorders that involve avoidance behaviors, as REBT aims to change the patient’s thinking prior to changing his or her behaviors. The study mentioned above clearly showed that changing the behavior alone, even when it was replaced with a new behavior was not sufficient to alleviate the symptoms of the disorder. The presence of the therapist in the situation provided a new stimulus for the patient, leading the avoidance behavior to be replaced with a new behavior with greater ease, however, it is possible to suggest that: one, the avoidance behavior may come back the next time the patient is in a similar situation with no therapist present; and two, changing the patient’s thinking, in addition to changing his or her behavior, may prove a more permanent way of changing his or her behavior in the future.
Another study illustrating the importance of perception, a key element in REBT, was conducted on the cultural differences in the perception of facial emotion between North American and Asian individuals. (Masuda, Mequita, Tanida, Ellsworth, Leu, and Van de Veerdonk, 2008). The researchers found that there was a clear difference in the way North Americans and the Japanese perceived emotion. When shown pictures of cartoon characters clearly expressing different facial emotions, North Americans judged what emotion the character experienced based solely on the character’s facial expression, while the Japanese participants were clearly more influenced by the facial emotions displayed by the surrounding characters. (p. 377)
This illustrates an important cultural difference in perception. While Westerners, North Americans in this study, but also Europeans the studies reviewed by the researchers as background for the current study, perceive emotion as an individual expression, regardless of context, Asian individuals are much more likely to pay attention to the context, perceiving an individual as inseparable from other people, and therefore judge emotion based on the entire picture. (p. 367).
While this study shows the obvious importance of perception on one’s thinking and judgement, other studies on perception suggest similar conclusions. Walbers, House, and Steele (1973) measured the differences in attitudes towards different aspects of school work in London school boys, ages 11 through 15. The researchers found that class participation, independent activities, excitement, and involvement were perceived as more prominent in earlier grades than in higher grades with older boys. (p.144) The results of the study suggest that perceptions of and attitudes towards classroom activities clearly changed as the boys got older, though the activities themselves remained largely the same. This, once again, demonstrates the importance of such perceptions on one’s thinking. It also suggests that children, as well as adults are similarly affected by perceptions.
The implication of these findings as relates to REBT is clearly that perception may be one of the most important aspects when judging a situation. Therefore, REBT can prove to be of great importance in situations where individual perceptions cause one to behave in a maladaptive way.
Some available research also points to the fact that REBT can prove useful in treating neurotic disturbances. In a study on emotional overproduction, neuroticism and rumination, Hervas and Vazquez (2011) found a significant connection between ruminative styles, or a tendency to focus on depressive symptoms, causes, or consequences of those symptoms, otherwise often referred to as neurosis. (p. 881) The researchers found that emotional overproduction, defined as the chronic tendency to experience a high number of negative emotions along with sadness, contributed to neuroticism-ruminative style of thinking, suggesting that emotional overproduction contributes to rumination, as a reaction to negative experiences in people with neuroticism. (p. 883)
An interesting outcome of the study was that neither participants’ current mood nor their emotional clarity could explain the relation, once again pointing to the fact that it is the long-term way of thinking that is important in addressing how one interprets negative events, and related to this, how one reacts to these events, rather than one’s current mood. (p. 887) This finding was also confirmed by a study measuring the reliability and validity of discrete and continuous measures of psychopathology, which found that continuous measures were more reliable than discrete measures across a wide range of settings. (Chmielewski and Miller, 2011) The meta-analysis of 58 studies with the total of 59,575 participants showed a 15% increase in reliability and a 37% increase in validity as a result of the adoption of continuous, versus discrete, measures, once again illustrating that when it comes to psychopathologies, long term stimuli are more likely to have an effect. (p. 856)
In their study, Hervas and Vazquez were not only able to come out with results in support of this, but also found that some individuals have a tendency to experience additional emotions, which are not directly related to the situation, but appear as a consequence of their reaction to the situation. (p.892) The example given by the researchers is that of an initial reaction of embarrassment leading the individual to experience irritation, disappointment in self, or anger. This example clearly illustrates that one’s perception of events, and even one’s reaction to them, plays an important role in how one feels about the event. Keeping these findings in mind, it is easy to imagine how two different people can perceive the exact same event, for example a job performance review, as positive (being able to receive feedback on one’s performance that can be used to improve his or her job performance in the future and possibly attain a promotion, or a better job), or negative (being unjustly criticized by one’s boss and co-workers). This is another indicator that REBT with its aim of changing one’s thinking at its core is much more likely to aid individuals whose ruminative style contributes to their neuroticism than traditional cognitive-behavior therapy.
Relating to the topic of the importance of thinking on perception is a Yale University report on the changes in psychiatric diagnosis over time. (Blum 1978) Blum set out to examine how psychiatric diagnoses have changed with the changes in perceptions of mental disease, definitions of certain mental disorders, adjustments to the Diagnosis and Statistical Manual (DSM), and other factors over time. The results of the study showed that over a 20-year period from 1954 to 1974 there was an increase in the number of diagnoses made for affective disorders, schizophrenia, and situational reactions. The same time-period also showed a decrease in neurosis and psychophysiological disorders diagnoses. (p. 1027) Blum also reports that at the time of the study, 1978, there was a clear disparity in the diagnoses made by British and American psychiatrists for the same symptoms. (p. 1028) Similarly, the treatments for the same symptoms have varied over a the time period in the study, leading Blum to suggest that using psychiatric diagnosis as a basis for the science of human behavior is a risky and unreliable undertaking. (p. 1029-30) All these suggesting that, though Blum’s primary focus was on the historical context of psychiatric diagnosis, various influence on perception, such as historical period as well as culture, play a role in how a disease is diagnosed and treated.
This finding was also supported by the outcome of a study that aimed to examine the co-occurrence of anxiety and depression amongst older adults in Latin America, India, and China. (Prina, Ferri, Guerra, Brayne, and Prince, 2011). The researchers based the study on previous findings for North American populations, where anxiety and depressive disorders are often found to be present together in adults, though studies reporting on the same disorders in older adults are less common. (p. 2047) The researchers report that the prevalence of ICD-10 depression was consistent across Latin American and Indian populations, but was much lower in the Chinese population. The researchers suggest that a feasible reason for this is the fact that there is a stigma attached to mental illness in China that is much greater than that in other cultures under examination here. (p. 2053)
These findings once again point at the importance of perception, and therefore of self-regulation in one’s thinking, rather than relying purely on one’s impulses and initial reactions to events.
Illuminating this issue from a different angle, there is a body of research suggesting that comorbidity plays an important role in experiencing depressive symptoms in individuals of varying social backgrounds and age groups. Following the findings made by Coyne, whose 1970s research was based on a hypothesis that dysphoric individuals induce negative affect in significant others, eventually leading to rejection and worsening depression, Conway, Burk, Rancourt, Adelman, and Pinstein set out to examine the extent to which youths’ depressive symptom levels became more similar to that of the members of their peer groups, a phenomenon known as depression socialization. (2011, p. 857) The results of the study showed that there was a clear tendency towards depression socialization in adolescents, as their own depression symptom levels adjusted over time to the social group they attached themselves to. (p.863) Interestingly, the researchers also found that girls, and those on the periphery of the peer group were more susceptible to depression socialization, suggesting that one’s gender and status in a hierarchy may play an role in how easily one is affected by the group, an implication also supported by the study that found that an adolescent’s status in the peer group influenced his or her implicit responses to other members of the peer group. (Lansu, Cillessen, and Karremans, 2012) The study demonstrated that popular and unpopular peers elicited different automatic responses in adolescents. (p.72)
Similarly, in the background literature review for the study by Conway et. al., the researchers report that previous studies have reported a temporal association between mother and child depression diagnoses, where child depressive symptoms varied with fluctuations in maternal symptoms; and loneliness reported by adults’ distal social network ties predicted adults’ own social distress over time. (Conway, Burk, Rancourt, Adelman, and Pinstein 2011, p.857) This, in conjunction with the research that supports the fact that there is substantial evidence that both the importance of peer groups and the increase in depression levels increase during adolescence, points to the fact that socialization is a very important factor for depression. In terms of REBT, when we examine an individual’s interactions within his or her social group, and the ways in which he or she thinks about and reacts to them, it is easy to see that the sucseptability to the group’s depression levels may be greatly reduced by the use of REBT, as changing the way one thinks about others’ experiences may help shield him or her from depression socialization. In other words, one may learn how to be supportive of his or her friends who are dealing with depression, without developing similar depressive symptoms.
Supporting this probability is a study of self-regulation as it contributes to adult development. (Busch and Hofer, 2012) Self-regulation, or being able to motivate oneself, pay attention, and inhibit spontaneous responses in favor of more productive ones, has been shown to be very important to individual well-being. Previous studies have found that those individuals who are better able to self-regulate generally experience less negative emotions and behavioral problems than those who self-regulate less efficiently. (Busch and Hofer p. 282) The researchers hypothesized that positive association between self-regulatory capacities and well-being is partly explained by the positive effect self-regulation has on the successful resolution of developmental crises, employing Eriksonian theory of personality development through crises and resolutions.
The researchers found that their hypothesis was indeed supported by the outcome, with a clear link between the ability to self-regulate and general individual well-being. In regards to personality development in adolescence, the researchers point out that Eriksonian stage of identity formation takes place during this time, and that self-regulation is clearly an important characteristic for the successful resolution of the conflict in the stage. Though peer groups and social pressure are unavoidable during this time, those adolescence who are better able to self-regulate their emotions display more positive affect and lower depression levels. (p. 289) Though the study did not sufficiently test whether the same is true for other age groups and developmental stages, it is easy to imagine that though other age groups may be less affected by their social groups, similar effects may be found, again making the central theory in REBT, or changing one’s dysfunctional thinking towards a more rational thought process relevant on this issue.
In fact, when examined from the point of view of personality development based on the Big Five model of personality, what REBT deems rational thinking is crucial to proper development, as it has been reported that the development of personality traits in early adulthood, in other words, maturation, is characterized by decreasing Neuroticism (or irrational thinking and behaviors), and increasing Agreeableness, Conscientiousness, and Openness (or rational thinking and behaviors). (Wright, Pincus, and Lenzenweger, 2011, p. 1351) When the researchers examined the development of personality in the context of the remission of personality disorder (PD), they found that maturation not only positively correlated with the remission of PD symptoms, but also that greater maturity was associated with better individual functioning and health. (p.1357)
These results were supported by another study of personality development factors, which set out to examine the interaction between parent and child personality characteristics and their effect on parenting styles. (Haan, Dekivic, and Prinzie, 2012) The study reported that there was a clear relationship between personality characteristics of both adolescents and parents, and parenting styles. The researchers established that more emotionally stable parents and parents of more Agreeable adolescents showed less over-reactivity and more support, while parents of less emotionally stable adolescents showed more warmth, however, the parents’ over-reactivity in this case depended on parent’s emotional stability. (p.196) The researchers also reported that their results supported previous findings that in general, temperamentally difficult children, who are high in negative emotional expressions, impulsivity, restlessness, and distractibility and low in frustration tolerance and fearfulness, evoke less positive and more negative behaviors in parents (p.191), clearly demonstrating the link between personality traits and overall well-being of both children and parents.
Though personality traits differ from one individual to another, and the developmental curve for personality is specific to each individual (Wright et. al.), these studies demonstrate that the way one’s personality develops, or in other words, the external factors that influence one’s personality, depend largely on the environment and the way the individual processes his or her environment. Therefore, though individuals who are naturally high in negative emotional expression may have to work harder to develop ways of dealing with their reality in a way that does not produce an immediate negative response, but rather allows them to come up with a better, more productive way to react to their environment, this can be achieved with the help of REBT. Moreover, since personality development is apparent even in childhood, and reaches its most rapid and crucial stage during adolescence, it is possible that REBT can be useful with children and adolescents, especially those who display behavioral or emotional problems and depression symptoms.
It is impossible to talk about REBT without continuously bringing up one’s perception of events, as according to this theory, it is the way we process what happens to us that is said to influence how we feel about it, not the events themselves. In this respect, a body of research on patients’ perception of their therapy, as well as on the way patients’ own beliefs influence therapy can be useful to examine. One aspect of this issue is therapists working with clients who are deeply religious.
It has been suggested that REBT is an excellent option for deeply religious clients, because the therapy is belief-based, and because most religions are in agreement with REBT’s theoretical notions about irrational thinking. (Nielsen, Johnson, and Ridley, 2000) The researchers report, however, that religious clients often become disturbed by their own faulty interpretations of religious texts, believing for example that they can never be good enough to please God, and leading to emotional disturbances, depression, behavior problems, etc. (p. 23). In this case, REBT can be applied by the therapist to demonstrate how the client’s interpretation is at fault, and how a different, more rational way of thinking about a passage in the Bible, or a general religious belief, such as “God doesn’t love me as much when I sin.” (p. 23) The researchers in this study found that adopting a religiously accommodating approach to REBT resulted in significant reductions in depression, automatic thoughts and general symptom distress when clients were instructed to amass a body of faith-specific evidence from their religious texts to counter their irrational beliefs and to use these daily in their thought processes. (p. 24 & 27)
Religion sensitivity has been demonstrated to be of great importance in therapy by other studies as well. Shumway and Waldo (2011) examined whether there would be an interaction between therapy participants’ levels of religiosity and their anticipated working alliance with a counselor who invites examination of religious issues in the informed consent statement. The researchers’ anticipation was that more religious clients would show a higher anticipated working alliance in response to the invitation to address religious issues, which proved to be true on three Working Alliance Inventory scales, clearly suggesting that clients’ religiosity must be taken into account during therapy.
In examining this interplay between religiosity and therapy, the researchers bring up the all-important issue of working alliance between the client and the therapist. The working alliance consists of three components: 1) agreement on in-counseling behavior, or tasks; 2) mutually agreed upon outcome of therapy, or goals; and 3) the client/counselor trust, confidence, and respect, or bond. (Shumway and Waldo, p. 2) It has to be noted that working alliance presupposes that both parties must be allowed to contribute during therapy, and therefore, client’s perspective must be taken into serious consideration by the therapist. In fact, Znoj, Caspar, and Jorg (2012) found that the introduction of a brief metacommunication intervention during thereapy, or in other words, valuing clients’ perspective, reinfored clients’ alliance with their therapists over the course of therapy. (p. 23)
This issue of working alliance was also examined from a different angle in a survey of counselor behaviors in terms of which behaviors are considered ethical and unethical by therapists across different fields. (Neukrug and Milliken, 2010). Interestingly, the survey found that though most counselors agreed on what constitutes ethical behaviors for a therapist, there is a clear historical influence on what is considered ethical, as is demonstrated by the adjustments in the ACA Code of Ethics, which has been recently revised to reflect the more current culture in which it is employed. (p. 206) When speaking about counselors’ code of ethics, as is based on the current times and culture, it is important to think of it as a product of the clients’ times and culture as well. In doing so, we can see that such revisions can be very important in establishing a functional working alliance between the client and the therapist, as both will behave in concurrence with what current norms dictate. It is also important to note in reviewing this study that, cultural norms aside, the counselors’ own perceptions determined to some extent what was considered ethical. For example, younger counselors saw it as more unethical to see only male or female clients or clients from specific cultural backgrounds. They also saw it as more unethical to keep records of their therapy sessions in an unlocked cabinet. Similarly, school counselors, who are generally not trained in diagnoses, saw making a diagnosis based on the DSM-IV as more unethical than other counselors. (p. 211)
These examples not only demonstrate the changing perceptions of what is considered ethical through time, as we can see from the differences between younger and older counselor’s survey data, but also the importance of the counselors’ perception and how it corresponds with the clients’ perception. For example, it the client were to find out that his or her records were kept in an unlocked cabinet, what would that do to the client-therapist trust? This issue once again can be said to show the importance of perceptions and beliefs when it comes to therapy. The conclusion that can be drawn from this study, besides the ones provided by the researchers, are that it is important for the client and the therapist to hold similar beliefs, or at least to allow, through rational thinking, for the possibility that someone else is entitled to hold beliefs that are somewhat different from his or her own.
This is a very important issue in REBT, as unlike other approaches to therapy, which take a more passive route, REBT puts the therapist in a position to make suggestions to the client, advise the client, and teach him or her new ways of thinking. Because of this back-and-forth interaction, it is crucially important that the client-therapist trust remains unbroken, and that the therapist is aware of what the client would consider ethical and unethical. It is also of heightened importance in REBT that the therapist has the required expertise to help the client, that he or she uses believable rationale and that the tasks of the therapy fit this rationale. (Westra, Arkowitz, Constantino, and Dozois, 2011, p. 289) The study of therapist differences performed by these researchers found that different therapists produced different outcomes in clients, that more effective therapists demonstrated higher CBT competence, and that clients of more effective therapists reported higher expectations of positive therapy outcome and higher working alliance quality. (p. 289)
It is easy to see how a therapist’s personality can be of great importance in REBT, because of the close proximity in which the therapist and the client work on the therapy issues. Interestingly, Johnson, Digiuseppe, and Ulven (1999) report that Albert Ellis, the founder of REBT is often described as cold, aloof, and abrasive, more interested in efficiency than in relationships. (p. 311) Even more interestingly, however, Ellis is reported to have engaged in numerous mentoring relationships throughout his career, though he did not initiate most of them, and is said to have provided considerable support, acceptance, and encouragement to his proteges. (p. 311) This suggests that though personality is important in working relationships, as well as the working relationships between therapists and clients, there are certain aspects of the therapist’s personality that are more important than others. For example, a therapist who is accepting and professional, allowing the client to express his or her ideas before offering advice, may have a much better result with a client than a therapist who is quick to offer his or her corrections to the way the client thinks.
Such accepting behavior can also be of great help on the issue of disclosure in therapy. It is easy to imagine that opening up to a therapist may be extremely difficult to some clients. In fact, a study of patients’ disclosures about therapy to their confidants, such as significant others, Khurgin-Bott and Farber (2011) found that not all therapy clients were comfortable disclosing the information about their therapy to their confidants. Reversely, we can incur that not all patents are comfortable disclosing certain information to their therapists, in which case, it is again, extremely important that the therapist act in a way which ensures trust, especially when the therapy in question is REBT, where the patient is expected to take direction from the therapist.
Conclusion
As an approach to therapy, REBT is a method that veers away from traditional therapy in numerous ways. First, REBT does not attempt to solve the patients’ problems as its main focus, but rather to change the way the patient thinks about them. Based on the idea that people are not affected by events themselves, but by the way they perceive them, REBT strives to change dysfunctional ways of perception.
REBT has been shown to be quite effective as a psychotherapy model, and as an aid to learning and cognition with populations of various age groups and ethnicities. As such, it eliminates a very common criticism of psychotherapy – the frequent failure of the patient to translate the insights gained in therapy to his or her every day life. (Khurgin-Bott and Farber p.335)
Some of the limitations of the current studies of REBT’s effectiveness include: the lack of understanding of some of the social-psychological systems underlying social interactions and how social bonds are formed (Conway, et. al.), the numerous predicting factors in personality development that may not be affected by learning or thought processes (Wright et. al.), and the fact that some studies employed results from either volunteers, or participants who were not in therapy or seeking therapy, possibly producing different results than they would had they used a randomly selected sample of therapy participants (Shumway and Waldo).
Overall, though more research would be useful on the exact mechanisms of REBT’s effectiveness, this method seems to produce real, long-lasting results in therapy participants, who report greater levels of the sense of well-being and better health long after participating in REBT.
