The central insight of cognitive therapy as originally formulated over three
decades ago is that thoughts mediate between stimuli, such as external events, and emotions. As in the figure below, a stimulus
elicits a thought — which might be an evaluative judgement of some kind — which in turn gives rise to an emotion.
In other words, it is not the stimulus itself which somehow elicits an emotional response directly, but our evaluation
of or thought about that stimulus. (Some practitioners use Ellis’s ABC model, described in the section on rational
emotive behaviour therapy, to describe the role of thoughts or attitudes mediating between events and our emotional responses.)
Two ancillary assumptions underpin the approach of the cognitive therapist: 1) the client is capable of becoming aware of
his or her own thoughts and of changing them, and 2) sometimes the thoughts elicited by stimuli distort or otherwise fail
to reflect reality accurately.
A common ‘everyday example’ of alternative thoughts or
beliefs about the same experience and their resulting emotions might be the case of an individual being turned down for
a job. She might believe that she was passed over for the job because she was fundamentally incompetent. In that case, she
might well become depressed, and she might be less likely to apply for similar jobs in the future. If, on the other hand,
she believed that she was passed over because the field of candidates was exceptionally strong, she might feel disappointed
but not depressed, and the experience probably wouldn’t dissuade her from applying for other similar jobs.
Cognitive therapy suggests that psychological distress is caused by distorted thoughts
about stimuli giving rise to distressed emotions. The theory is particularly well developed (and empirically supported) in
the case of depression, where clients frequently experience unduly negative thoughts which arise automatically even in response
to stimuli which might otherwise be experienced as positive. For instance, a depressed client hearing "please stop
talking in class" might think "everything I do is wrong; there is no point in even trying". The same client
might hear "you’ve received top marks on your essay" and think "that was a fluke; I won’t ever
get a mark like that again", or he might hear "you’ve really improved over the last term" and think
"I was really abysmal at the start of term". Any of these thoughts could lead to feelings of hopelessness or reduced
self esteem, maintaining or worsening the individual’s depression.
Usually cognitive therapeutic work is informed by an awareness of the role of the client’s behaviour as well (thus
the term ‘cognitive behavioural therapy’, or CBT). The task of cognitive therapy or CBT is partly to understand
how the three components of emotions, behaviours and thoughts interrelate, and how they may be influenced by external stimuli
— including events which may have occurred early in the client’s life.
Therapeutic Approach of Cognitive or Cognitive Behavioural Therapy
Cognitive
therapy aims to help the client to become aware of thought distortions which are causing psychological distress, and of behavioural
patterns which are reinforcing it, and to correct them. The objective is not to correct every distortion in a client’s
entire outlook — and after all, virtually everyone distorts reality in many ways — just those which may be at
the root of distress. The therapist will make every effort to understand experiences from the client’s point of view,
and the client and therapist will work collaboratively with an empirical spirit, like scientists, exploring the client’s
thoughts, assumptions and inferences. The therapist helps the client learn to test these by checking them against reality
and against other assumptions.
Often this process will continue outside
the therapeutic session. For instance, a client whose fear of dying in a car crash is causing them great anxiety when it
comes time to drive to work might record on a slip of paper their estimate of the odds of dying in a car crash at various
points in the morning — when they first get up, when they are nearly ready to leave the house, when they are almost
to the car, and when they are actually driving. (For someone experiencing such anxiety, these odds might go something like:
1,000 to 1 against when first getting up; 20 to 1 against when nearly ready to leave the house; 2 to 1 against when almost
to the car; 5 to 1 in favour of dying in a car crash when actually driving.) This can help the client to see that
their estimated odds of actually dying in a car crash are changing just as they move about the house and complete the morning
routine. This can be the first step toward making those estimates more realistic and reducing the anxiety which accompanies
the thought that one is very likely to die in a crash while driving.
Because of the interrelationship between thoughts, feelings and behaviours, therapeutic interventions frequently involve
the client’s behaviour. For instance, a client with a strong fear that squirrels will jump onto their head if they
walk under trees may go to great lengths to avoid walking under trees. This behaviour will prevent the client from acquiring
information that contradicts their thought that "if I walk under a tree, a squirrel will jump onto my head" or
perhaps their mental image of a squirrel jumping onto their head the moment they step under a tree. The therapist may help
the client to overcome this avoidance of walking under trees as part of the process of correcting the distorted thought
that walking under trees will lead to squirrels jumping on the client’s head.
Throughout this process of learning, exploring and testing, the client acquires coping strategies as well as improved
skills of awareness, introspection and evaluation. This enables them to manage the process on their own in the future, reducing
their reliance on the therapist and reducing the likelihood of experiencing a relapse.
Criticisms of Cognitive Therapy and CBT
On first hearing of the basic
cognitive therapeutic approach, many people will observe that simply being told that a view doesn’t accurately reflect
reality doesn’t actually make them feel any better. They might say, "I knowwhether
it reflects reality). This would be like criticising the person-centred approach on the grounds that a therapist merely telling
a client they are free to discuss anything they like, without judgement from the therapist, doesn’t make it feel
any easier to talk about difficult problems. squirrels aren’t likely to jump on my head, but
I can’t help worrying about it anyway". But to suggest that a cognitive therapist merely tells the client something
is wrong is to caricature the approach (and, in fact, few cognitive therapists would actually tell a client some view doesn’t
reflect reality anyway; they would help the client to explore
A more
salient criticism for some clients may be that the therapist initially may fulfil something of an authority role, in the
sense that they provide problem solving experience or expertise in cognitive psychology. Some people may also feel that
the therapist can be ‘leading’ in their questioning and somewhat directive in terms of their recommendations.
Best Fit With Clients
Clients who are comfortable with introspection,
who readily adopt the scientific method for exploring their own psychology, and who place credence in the basic theoretical
approach of cognitive therapy, may find this approach a good match. Clients who are less comfortable with any of these,
or whose distress is of a more general interpersonal nature — such that it cannot easily be framed in terms of an interplay
between thoughts, emotions and behaviours within a given environment — may be less well served by cognitive therapy.
Cognitive and cognitive-behavioural therapies have often proved especially helpful to clients suffering from depression,
anxiety, panic and obsessive-compulsive disorder.
Cognitive-Behavioral
Therapy
Cognitive-Behavioral Therapy (CBT) is an empirically supported
treatment that focuses on patterns of thinking that are maladaptive and the beliefs that underlie such thinking. For example,
a person who is depressed may have the belief, "I’m worthless," and a person with a phobia may have the
belief, "I am in danger." While the person in distress likely holds such beliefs with great conviction, with a
therapist’s help, the individual is encouraged to view such beliefs as hypotheses rather than facts and to test out
such beliefs by running experiments. Furthermore, those in distress are encouraged to monitor and log thoughts that pop
into their minds (called "automatic thoughts") in order to enable them to determine what patterns of biases in
thinking may exist and to develop more adaptive alternatives to their thoughts. People who seek CBT can expect their therapist
to be active, problem-focused, and goal-directed.
Studies of CBT have
demonstrated its usefulness for a wide variety of problems, including mood disorders, anxiety disorders, personality disorders,
eating disorders, substance abuse disorders, and psychotic disorders. While a full description of the treatment and presenting
problems for which it is useful is beyond the scope of this brief overview, a brief summary of several treatments will be
presented.
CBT has been shown to be as useful as antidepressant medication
for individuals with depression and is superior in preventing relapse. Patients receiving CBT for depression are encouraged
to schedule activities in order to increase the amount of pleasure they experience. In addition, depressed patients learn
how to restructure negative thought patterns in order to interpret their environment in a less biased way. CBT for Bipolar
Disorder is used as an adjunct to medication treatment and focuses on psychoeducation about the disorder and understanding
cues and triggers for relapse. Studies indicate that patients who receive CBT in addition to treatment with medication have
better outcomes than patients who do not receive CBT as an adjunctive treatment.
CBT is also a useful treatment for anxiety disorders. Patients who experience persistent panic attacks are encouraged
to test out beliefs they have related to such attacks, such as specific fears related to bodily sensations, and to develop
realistic responses to such beliefs. This treatment is very effective for those who experience such problems. Patients who
experience obsessions and compulsions are guided to expose themselves to what they fear and beliefs surrounding their fears
are identified and modified. The same is true for people with phobias, including phobias of animals or phobias of evaluation
by others (termed Social Phobia). Those in treatment are exposed to what they fear and beliefs that have served to maintain
such fears are targeted for modification.
Over the past 10 years, CBT
for schizophrenia has received considerable attention in the United Kingdom. While this treatment continues to be in its
infancy in the United States, the results from studies in the United Kingdom have stimulated considerable interest in therapists
in the U.S., and more therapists are conducting the treatment now than just a few years ago. In this treatment, patients
are encouraged to identify beliefs and their impact and to engage in experiments to test their beliefs. Treatment focuses
on thought patterns that cause distress and also on developing more adaptive, realistic interpretations of events. Delusions
are treated by developing an understanding of the kind of evidence the person uses to support the belief and encouraging
the patient to recognize evidence that may have been overlooked that does not support the belief. Furthermore, the assumed
omnipotence of "voices" is tested, and patients are encouraged to utilize various coping mechanisms to test the
controllability of auditory hallucinations.
While the above summary is
certainly not comprehensive, it provides a brief overview of the principles of CBT and how it applies to various presenting
problems. CBT’s focus on thoughts and beliefs are applicable to a wide array of issues. Because CBT has excellent empirical
support, it has achieved wide popularity both for therapists and consumers. Those who may receive CBT training include psychologists,
psychiatrists, social workers, and psychiatric nurses. Those seeking treatment using a CBT approach are encouraged to ask
their therapist what CBT training they have had or to contact a Center for Cognitive Therapy and request a referral in their
geographical location.
Reviewed by Debbie M.
Warman, Ph.D. and Aaron T. Beck, M.D., June 2003
What is
REBT?
Rational Emotive Behavior Therapy (REBT) is a form of psychotherapy
created by Albert Ellis in the 1950's.
REBT (pronounced R.E.B.T. — it is not pronounced
rebbit) is based on the premise that whenever we become upset, it is not the events taking place in our lives
that upset us; it is the beliefs that we hold that cause us to become depressed, anxious, enraged, etc. The idea that our
beliefs upset us was first articulated by Epictetus around 2,000 years ago: "Men are disturbed not by events, but
by the views which they take of them."
The Goal of Happiness
According to Albert Ellis and to REBT, the vast majority of us want to be happy.
We want to be happy whether we are alone or with others; we want to get along with others—especially with one or two
close friends; we want to be well informed and educated; we want a good job with good pay; and we want to enjoy our leisure
time.
Of course life doesn't always allow us to have what we want; our
goal of being happy is often thwarted by the "slings and arrows of outrageous fortune." When our goals are blocked,
we can respond in ways that are healthy and helpful, or we can react in ways that are unhealthy and unhelpful.
The ABC Model
Albert Ellis
and REBT posit that our reaction to having our goals blocked (or even the possibility of having them blocked) is determined
by our beliefs. To illustrate this, Dr. Ellis developed a simple ABC format to teach people how their beliefs cause their
emotional and behavioral responses:
A.
Something happens.
B . You have a
belief about the situation.
C. You
have an emotional reaction to the belief.
For example:
A. Your employer falsely accuses you of taking money
from her purse and threatens to fire you.
B . You believe, “She has no right to accuse me. She's a bitch!”
C
. You feel angry.
If
you had held a different belief, your emotional response would have been different:
A. Your employer falsely accuses you of taking money from her purse and threatens to fire you.
B . You believe, “I must not lose
my job. That would be unbearable.”
C . You feel anxious.
The ABC model shows that A
does not cause C. It is B that causes C. In the first example, it is not
your employer's false accusation and threat that make you angry; it is your belief that she has no right to accuse you,
and that she is a bitch. In the second example, it is not her accusation and threat that make you anxious; it is the belief
that you must not lose your job, and that losing your job would be unbearable.
The Three Basic Musts
Although we all express ourselves differently,
according to Albert Ellis and REBT, the beliefs that upset us are all variations of three common irrational beliefs. Each
of the three common irrational beliefs contains a demand, either about ourselves, other people, or the world in general.
These beliefs are known as "The Three Basic Musts."
- I must do well and win the approval of others for my performances
or else I am no good.
- Other people must treat me considerately, fairly
and kindly, and in exactly the way I want them to treat me. If they don't, they are no good and they deserve to be condemned
and punished.
- I must get what I want, when I want it; and I must not get
what I don't want. It's terrible if I don't get what I want, and I can't stand it.
The first belief often leads to anxiety, depression, shame, and guilt. The second belief often leads to rage, passive-aggression
and acts of violence. The third belief often leads to self-pity and procrastination. It is the demanding nature of the beliefs
that causes the problem. Less demanding, more flexible beliefs lead to healthy emotions and helpful behaviors
Disputing
The goal of REBT
is to help people change their irrational beliefs into rational beliefs. Changing beliefs is the real work of therapy and
is achieved by the therapist disputing the client's irrational beliefs. For example, the therapist might ask, "Why
must you win everyone's approval?" "Where is it written that other people must treat you fairly?"
"Just because you want something, why must you have it?" Disputing is the D of the ABC
model. When the client tries to answer the therapist's questions, s/he sees that there is no reason why s/he absolutely must
have approval, fair treatment, or anything else that s/he wants.
Insight
Albert Ellis and REBT contend that although we all think irrationally from time
to time, we can work at eliminating the tendency. It's unlikely that we can ever entirely eliminate the tendency to think
irrationally, but we can reduce the frequency, the duration, and the intensity of our irrational beliefs by developing three
insights:
- We don't merely get upset but mainly upset ourselves
by holding inflexible beliefs.
- No matter when and how we start
upsetting ourselves, we continue to feel upset because we cling to our irrational beliefs.
- The only way to get better is to work hard at changing our beliefs. It takes practice,
practice, practice.
Acceptance
Emotionally healthy human beings develop an acceptance of reality, even when reality is highly unfortunate and unpleasant.
REBT therapists strive to help their clients develop three types of acceptance: (1) unconditional self-acceptance; (2) unconditional
other-acceptance; and (3) unconditional life-acceptance. Each of these types of acceptance is based on three core beliefs:
Unconditional self-acceptance:
- I
am a fallible human being; I have my good points and my bad points.
- There
is no reason why I must not have flaws.
- Despite my good points and my
bad points, I am no more worthy and no less worthy than any other human being.
Unconditional other-acceptance:
- Other people will
treat me unfairly from time to time.
- There is no reason why they must
treat me fairly.
- The people who treat me unfairly are no more worthy and
no less worthy than any other human being.
Unconditional life-acceptance:
- Life doesn't always work out the way that I'd like it to.
- There is no reason why life must go the way I want it to
- Life is not necessarily pleasant but it is never awful and it is nearly always bearable.
REBT Today
Clinical experience
and a growing supply of experimental evidence show that REBT is effective and efficient at reducing emotional pain. When
Albert Ellis created REBT in the 1950's he met with much resistance from others in the mental health field. Today it is one
of the most widely-practiced therapies throughout the world. In the early days of REBT, even Dr. Ellis did not clearly see
that consistent use of its philosophical system would have such a profound effect on the field of psychotherapy or on the
lives of the millions of people who have benefited from it.
Shameless
Happiness
This introduction to REBT is based on Shameless Happiness, a concise booklet that outlines the basics of REBT.
