Fluent Essays

Using case #2 in the "case examples" pdf, apply your knowledge of cognitive-behavioral theory through a case analysis/conceptualization and basic treatment plan. Critically analyze the benefits and challenges of this approach. Apply Cognitive-Behavioral Theory to the case in both conceptualization and treatment plan. Further instructions and rubric guidelines are listed in the "final paper instructions and rubric" pdf. Be sure to utilize information from the "CBT" pdf or the "Corey Ch 10" pdf when conceptualizing and developing a treatment plan for case 2. In addition, be sure to include reliable outside sources to conceptualize and develop a treatment plan. Make sure to properly cite those sources as well. I want a minimum of 4 outside sources included in this essay that is related to CBT or to the CBT treatment plan. Case #1: Yisel Yisel is a 21-year-old Mexican American female. She is a college junior, Psychology major coming into the U of M counseling center seeking career counseling. She came in to get help with procrastination in applying for medical school. Yisel reports that she has no motivation because she doesn’t have the grades to get into medical school. She has a C average in her science classes but A’s and B’s in her Psychology courses. Yisel reports that whenever she sits down to work on applications, she finds herself wasting hours on the internet or hanging out with her friends. During her intake session, she reports that she has sleep difficulties, having nightmares several nights a week. In one nightmare, she described being unable to get her family out of a burning building. In another nightmare, she reported being kicked out of medical school because she failed all of her courses. She also reported that she has begun smoking marijuana daily because it helps her to relax and forget about her worries. Yisel reported that she is trying out counseling because she believes it will help her get her medical school applications done. Yisel’s married parents both live in Chicago with her four siblings. Her parents immigrated to Minnesota from Mexico in the early 1980s. Yisel and her two brothers were born in Chicago, and her older sister was born in Mexico. Her father works as a mechanic and her mother works as a secretary in Yisel’s former middle school. Both her parents were college educated in Mexico, but her parents had difficulty finding jobs in their fields because of language barriers and difficulty in having their credentials accepted in the US. Yisel talked about her parents’ hopes for her to become a doctor, which they once had for her older sister. Yisel reported that her old sister has “failed” her parents’ expectations; her older sister is currently unemployed, batting depression, and living at home. She says that although her parents have never explicitly pressured her to become a doctor, they have frequently expressed that “she is the smart one” in the family. Her parents also have indicated to Yisel that they will need her financial assistance to help pay for her younger brothers’ college tuition. Yisel says that her parents made many sacrifices to put her through school, which makes her feel guilty and selfish. She says that she feels like she will never be good enough, and that her parents will be disappointed in her if she does not follow through with her plans. When asked about her current ways of coping with her stress, she says that she enjoys running, cooking, and spending time with her friends. Her favorite part of her week is tutoring struggling high school students. She says that she is happiest when she is helping others. Case #2: Wesley Wesley is a 36-year-old White American male seeking counseling for his depression and anxiety. For the last two years, he has been taking medication for his depression prescribed by a psychiatrist. He finally decided to seek counseling at the suggestion of his psychiatrist. He indicated that “it is unlikely” counseling will make him feel better. Wesley feels that he has been in a “constant state of blue” for the last five years, finding it difficult to get out of bed most days out of the week and lacking the energy and interest to do the many things he formerly enjoyed, such as hiking and spending time with his children, Luke and Andy (ages 10 and 8). When asked about possible triggers for his depressed mood, Wesley says that his marriage and work life have not turned out as he hoped. Wesley and his wife, Lindsey, have been married for ten years. He says that he thought, “Lindsey was initially perfect for me”, but now Wesley is unable to see past her flaws. He reported that Lindsey “is always working and won’t make time for him.” Wesley reports that in order to “teach her a lesson about what’s important,” that he has basically stopped communicating with Lindsay. Wesley cannot remember the last me that he and his wife were physically or emotionally intimate. Wesley reported that “there is nothing he can do to fix the marriage” -- that it is up to Lindsey to make it better. Another reported concern is Wesley’s vocational life. The neighborhood that Wesley grew up in was middle-class; his mother is a middle-school English teacher, and his father owns a business that does contracting for housing developments. Since Wesley is an only child, his father would tell him, “The baby [i.e., the business] is all yours when you become a man.” Currently, Wesley acts as a sales manager for the company. He says that he feels trapped in his job and comes home frustrated every day, sometimes taking it out on Lindsey and the kids with angry outbursts. He also reported that he drinks a six-pack of beer every night in order to “get away from it all.” Growing up, Wesley always dreamed of being an actor. He staged plays for an audience that consisted of his parents (who divorced when he was 15 years old) and stuffed animals. He later starred in many high school productions but never further pursued this once he went to college to study business. He says that he felt like he had to “become an adult and let go of those silly fantasies.” Although Wesley has considered joining community theater productions, he says that he doesn’t have time and that he must be a “man” and provide for his children. Case #3: Sarah Sarah is a 31-year-old, biracial, Native American/White woman who presented at a community clinic with symptoms of anxiety. She grew up in a small town in rural Montana, and has been living in Minneapolis for much of the past 12 years. She has completed some college, during which time she switched majors numerous times. She reports that she currently works two part-time jobs in retail, and notes difficulty in making sure she gets enough shifts at work to cover her bills. Sarah would like to return to school, but is anxious about going into more debt. She has thoughts of going into nursing, or becoming a doctor, though she sometimes thinks she is too old to pursue those degrees, and wishes she had completed school earlier. When asked about her reasons for leaving college previously, Sarah states that she was experiencing anxiety at that time, and had a hard time focusing on completing coursework. Particularly, she reported that at the time, she was very concerned about her mother who had problems with alcoholism. Sarah reports that while growing up, she was closer to her mother, who is Native American, a police officer, and was involved in tribal politics, than to her father, who is White and a well- respected political figure in their town. Within the family, however, she reported, her father was often angry and verbally abusive, particularly toward Sarah. She also noted that she is close to her one sibling, an older brother who is happily married and working as an accountant in another state, but she sometimes feels like a failure when she compares her life to her brother’s. Sarah rarely returns to her hometown, and currently has little contact with her parents; the thought of visiting them produces high anxiety for her. When asked, Sarah denied having experienced racism or discrimination, but reflected that growing up, she was “the White kid” when spending time with other Native Americans, but was viewed as Native American by her predominantly White classmates. Currently, she does not feel very connected to her Native American heritage, and states that though she misses some parts of the culture, she also associates it with her conflicts her parents. Sarah reports no major medical issues, and denies any chemical dependency concerns. However, upon questioning, she reports that when her anxiety is very high, sometimes (about once a week recently) she smokes cigarettes. Sarah reports that she is not currently in a romantic relationship. However, she describes a wide circle of friends whom she spends time with socially, but notes that she rarely confides in any of her concerns to these friends. Sarah would like to feel less anxious and more satisfied with her life. Theoretical Case Analysis Final Paper​ ​Instructions Due Wednesday, November 18th at 11:59 PM CST on Canvas Assignment Goal:​ Using one of the provided Case Examples, apply your knowledge of the theories covered in class through a case analysis/conceptualization and basic treatment plan. Critically analyze the benefits and challenges of this approach. Assignment Directions: Overview Choose​ one​ of the Case Examples posted on the class website. ​Select ​one theory​ that we have already covered in lecture, including Psychodynamic, Feminist, Humanist, Behavior, Cognitive, Mindfulness, or Experiential.​ You may ​not​ choose Integrative, Family, Couples, Group, any Career/Vocational theories, or any other theories. Apply the ​same theory​ to the case in both conceptualization and treatment plan. General Outline First​, ​analyze the case​ in the language of the theory. In other words, ​how would a therapist from your chosen theoretical orientation describe the client and the presenting issues​, including description of the client (e.g., demographics, important biographical information), the nature of the issues and how they are maintained, and hypotheses about their origin. Be sure to provide evidence from the person’s life that suits this type of conceptualization (using details from the Case Example or hypothesizing about the client’s life). Also, consider what additional information/evidence you’d want to gather, given the theory that you’ve chosen. Second, ​provide a basic treatment plan​ for this client’s presenting concerns from this theoretical orientation. According to your chosen theory, what is the counselor’s role? How might this role be helpful, of little use, or even harmful in this situation? Outline some approaches to treatment. When you provide a treatment plan, consider the reasons why each intervention, strategy, or technique might produce change. When and how might you employ each technique or strategy? Third, ​address the strengths and limitations​ of your conceptualization and treatment plan. You should discuss this with respect to ways in which the conceptualization may be appropriate or inappropriate for this particular client or this particular presenting problem. For example, how might this conceptualization ignore important aspects of the case? What are the cultural considerations in using this theory/therapy with this client? (The key in this section is to make your discussion specific to the case, rather than a general commentary on the strengths and limitations of the theory). Tip:​ Demonstrate your knowledge of the theory in your ​application​ to the case example, rather than simply stating the principles of the theory or the general limitations of the theory. We expect that most of you will use lecture material and course readings as references. You do not have to cite lecture material, but ​please cite other materials appropriately​. Formatting Guidelines: Each paper should be approximately 5-6 pages (not including title page and references), double-spaced and in a 12-point Times New Roman font. Deviation from these guidelines will result in reduced points. Feel free to use first (i.e., pretending you are the therapist) or third person. These should be written in the general format of an essay in APA format (i.e., headings, Revised 11/4/2019    running head, page numbers, title page, & relevant citations in proper format); however you will not have an abstract, results, methods, or discussion sections. ***​Papers are due on Canvas by 11:59PM CST on Wednesday, November 18th ​*** Late Policy If you know you will be unable to turn in a paper on the day it is due, please make arrangements with the instructors ​at least one week in advance​. If no prior arrangement is made, all late assignments will be marked down a full 10% for each day they are late (i.e., the 10% deduction will apply to papers submitted after 11:59PM CST on 11/18). If you have a legitimate, documented excuse and contact the instructors within 24 hours, your grade will NOT be marked down. Please see ​http://policy.umn.edu/education/makeupwork​ ​for information about accepted excuses. This is worth 15% of your grade. Grading Philosophy Assignments will be graded with attention to both content and overall quality, which includes grammar, spelling, and adherence to assignment guidelines. ​Please follow the assignment directions and​ ​take the time to proofread/edit your papers​. If the paper’s mechanical issues detract from the content, your grade will reflect this. General Tips for Successful Papers 1. Meet with your TA. ​Your TA will be grading your paper, and you can meet with them to discuss your ideas or ask questions. While they cannot proofread or edit your papers, it is a good opportunity to understand your TA’s expectations when grading your paper. Often students are confused or upset when receiving their final paper grades. ​The best way to avoid being unhappy about your paper grade is to be proactive and meet with your TA ​prior​ to turning in your paper. 2. Develop a theme. a. State your message clearly and concisely in your opening paragraph. b. Conclude with a paragraph that restates the main point(s) you hope to convey. c. The theme should be clear, concise, and specific – rather than global and generalized. If you write in an overly general manner, your essays will lack a clear focus. d. Develop your thoughts fully, concretely, and logically. Both vagueness and verbosity often demonstrate a lack of familiarity with the theory. e. In terms of form and organization, your paper should flow well, and your points should relate to one another. The reader should not have to struggle to discover your intended meaning. f. Give reasons for your views, rather than making unsupported statements. When you take a position, provide reasons for your position. 3. Use examples. ​In developing your ideas, use clear examples to illustrate your point. Tie your examples into the point you are making, but avoid giving too many details that are irrelevant to the point. 4. Creativity and depth of thinking. ​Write a paper that reflects your own uniqueness and ideas, rather than merely giving a summary of the material in the texts. Revised 11/4/2019    http://policy.umn.edu/education/makeupwork a. Focus on a clear position that you take on a specific question or issue. b. Approach the material in an original way. c. Focus on a particular issue or topic that you find personally significant. Since you have a choice in what aspect to focus on, select an aspect of a problem that will allow you to express your beliefs. d. Show depth in expanding on your thoughts. 5. Application of the theory to the client and his/her presenting concerns. ​Many students in the past have had trouble writing papers that ​effectively apply the theory​ to their specific client and his/her presenting problem. This should be done at each appropriate point in the paper – for the conceptualization, the treatment plan, and the advantages and disadvantages of this theory. Again, the point of the paper is to demonstrate your knowledge through critical application of the theory, not just regurgitation. Please consult the grading rubric below. Theoretical Case Analysis - Grading Rubric Conceptualization 22 Points Total Discussion of relevant demographic and background information: _____ / 5 Analysis of the presenting program according to the theory (including how and why the issues are manifesting): _____ / 17 Treatment plan 25 Points Total Discussion of role of counselor: ____ / 12 Description and rationale of treatment: _____ / 13 Strengths & Limitations 16 Points Total Discussion of strengths of theory and treatment: ____ / 8 Discussion of limitations of theory and treatment: ____ / 8 Overall quality 12 Points Total Grammar, proof-reading, clarity of writing Follows formatting guidelines and APA style (running head, page numbers, title page, & relevant citations in proper format) ____/ 6 ____/ 6 Final Grade ____ / 75 Revised 11/4/2019    Cognitive-Behavioral Therapy Cognitive Behavior Therapies Albert Ellis's Rational Emotive Behavior Therapy Aaron Beck's Cognitive Therapy RATIONAL EMOTIVE BEHAVIOR THERAPY (REBT) What is REBT? • REBT was the first cognitive behavior therapy and is based on the assumption that cognitions, emotions, and behaviors interact with each other and have a mutual cause-and-effect relationship. How do problems develop? • Irrational beliefs, learned in childhood, are re-created throughout the lifetime and keep dysfunctional attitudes alive and operative. How does change occur? 4 steps for REBT 1. Show incorporation of irrational “oughts,” “shoulds,” and “musts” 2. Demonstrate how clients reinforce emotional disturbances through illogical thinking 3. Help modify thinking and minimize irrational thinking 4. Develop a rational life philosophy Role of therapist and client • A warm relationship is not required; counter-productive • Client expected to – Learn how to apply rational thought – Participate in experiential exercises – Complete behavioral homework COGNITIVE THERAPY (CT) What is CT? • Cognitive therapy is similar to REBT and behavior therapy. How do problems develop? • CT perceives psychological problems develop from common processes, such as faulty thinking, making incorrect inferences, and failing to distinguish between fantasy and reality. Cognitive distortions Selective abstraction Magnification and minimization Personalization Labeling and mislabeling Dichotomous thinking Arbitrary inferences How does change occur? • Modify inaccurate thinking • Learn to engage in more realistic thinking Role of therapist and client • Relationship between therapist and client is seen as necessary for the techniques to be applied • Both therapist and client take active roles How are REBT and CT different? REBT • Directive, persuasive, confrontational • View of faulty thinking as irrational and nonfunctional • Irrational thoughts mostly revolve around “should” and ”ought” CT • Emphasis on helping clients identify misconceptions for themselves • Beliefs as inaccurate, not irrational • Wide variety of cognitive distortions • Clients conduct behavioral experiments to test accuracy of beliefs Implications • Cognitive behavioral therapy (CBT) adds some behavioral techniques to pure cognitive therapy. It is the most well-researched and supported type of therapy; it is one of the most widely used Cultural considerations • The process begins from the client’s worldview – Can be helpful and/or not helpful! • For some clients who value interdependence, CBT can be too “directive” and not “reflective” enough • Important for therapist to also consider systems (gender, race…) surrounding individual – 272 – C H A P T E R T E N k Introduction k Albert Ellis’s Rational Emotive Behavior Therapy k Key Concepts View of Human Nature View of Emotional Disturbance A-B-C Framework k The Therapeutic Process Therapeutic Goals Therapist ’s Function and Role Client ’s Experience in Therapy Relationship Between Therapist and Client k Application: Therapeutic Techniques and Procedures The Practice of Rational Emotive Behavior Therapy Applications of REBT to Client Populations REBT as a Brief Therapy Application to Group Counseling k Aaron Beck ’s Cognitive Therapy Introduction Basic Principles of Cognitive Therapy The Client–Therapist Relationship Applications of Cognitive Therapy k Donald Meichenbaum’s Cognitive Behavior Modifi cation Introduction How Behavior Changes Coping Skills Programs The Constructivist Approach to Cognitive Behavior Therapy k Cognitive Behavior Therapy From a Multicultural Perspective Strengths From a Diversit y Perspective Shortcomings From a Diversit y Perspective k Cognitive Behavior Therapy Applied to the Case of Stan k Summary and Evaluation Contributions of the Cognitive Behavioral Approaches Limitations and Criticisms of the Cognitive Behavioral Approaches k Where to Go From Here Recommended Supplementary Readings References and Suggested Readings Cognitive Behavior Therapy – 273 – A L B E R T E L L I S ALBERT ELLIS (1913–2007) was born in Pittsburgh but escaped to the wilds of New York at the age of 4 and lived there (except for a year in New Jersey) for the rest of his life. He was hospitalized nine times as a child, mainly with nephritis, and developed renal glycosuria at the age of 19 and diabetes at the age of 40. By rigor- ously taking care of his health and stubbornly refusing to make himself miserable about it, he lived an unusually robust and energetic life, until his death at age 93. Realizing that he could counsel people skillfully and that he greatly enjoyed doing so, Ellis decided to become a psychologist. Believing psychoanalysis to be the deepest form of psychotherapy, Ellis was analyzed and supervised by a training analyst. He then practiced psy- choanalytically oriented psychotherapy, but eventually he became disillusioned with the slow progress of his cli- ents. He observed that they improved more quickly once they changed their ways of thinking about themselves and their problems. Early in 1955 he developed rational emotive behavior therapy (REBT). Ellis has rightly been called the “grandfather of cognitive behavior therapy.” Until his illness during the last two years of his life, he generally worked 16 hours a day, seeing many clients for individual therapy, making time each day for professional writing, and giving numerous talks and workshops in many parts of the world. To some extent Ellis developed his approach as a method of dealing with his own problems during his youth. At one point in his life, for example, he had exag- gerated fears of speaking in public. During his adoles- cence he was extremely shy around young women. At age 19 he forced himself to talk to 100 diff erent women in the Bronx Botanical Gardens over a period of one month. Although he never managed to get a date from these brief encounters, he does report that he desen- sitized himself to his fear of rejection by women. By applying cognitive behavioral methods, he managed to conquer some of his strongest emotional blocks (Ellis, 1994, 1997). People who heard Ellis lecture often commented on his abrasive, humorous, and fl amboyant style. He did see himself as more abrasive than most in his work- shops, and he also considered himself humorous and startling in some ways. In his workshops he took delight in giving vent to his eccentric side, such as peppering his speech with four-letter words. He greatly enjoyed his work and teaching REBT, which was his passion and primary commitment in life. Even during his fi nal ill- ness, he continued to see students at the rehabilitation center where he was recuperating, sometimes teaching from his hospital bed. One of his last workshops was to a group of students from Belgium who visited him in the hospital. In addition to pneumonia, he had had a heart attack that morning, yet he refused to cancel this meeting with the students. Humor was an important part of his philosophy, which he applied to his own life challenges. Through his example, he taught people how to deal with serious adversities. He enjoyed writing rational humorous songs and said that he would have liked to be a composer had he not become a psychologist. Ellis married an Australian psychologist, Debbie Joff e, in November 2004, whom he had called “the great- est love of my life” (Ellis, 2008). Both of them shared the same life goals and ideals and they worked as a team presenting workshops. For more on the life of Albert Ellis and the history of REBT, see Rational Emotive Behavior Therapy: It Works for Me—It Can Work for You (Ellis, 2004a). Co ur te sy o f A lb er t E lli s In st it ut e Introduction As you saw in Chapter 9, traditional behavior therapy has broadened and largely moved in the direction of cognitive behavior therapy. Several of the more prominent cognitive behavioral approaches are featured in this chapter, including Albert Ellis’s rational emotive behavior therapy (REBT), Aaron T. Beck’s cognitive therapy (CT), and Donald Meichenbaum’s cognitive behavior – 274 – AARON TEMKIN BECK (b. 1921) was born in Providence, Rhode Island. His childhood was char- acterized by adversity. Beck’s early schooling was interrupted by a life-threatening illness, yet he overcame this problem and ended up a year ahead of his peer group (Weishaar, 1993). Throughout his life he struggled with a variety of fears: blood injury fears, fear of suff ocation, tunnel phobia, anxi- ety about his health, and public speaking anxiety. Beck used his personal problems as a basis for understanding others and developing his theory. A graduate of Brown University and Yale School of Medicine, Beck initially practiced as a neurologist, but he switched to psychiatry during his residency. Beck is the pioneering fi gure in cognitive therapy, one of the most infl uential and empirically validated approaches to psychotherapy. Beck’s conceptual and empirical contributions are considered to be among the most signifi cant in the fi eld of psychiatry and psychotherapy (Padesky, 2006). Beck attempted to validate Freud’s theory of depression, but his research resulted in his parting company with Freud’s motivational model and the explanation of depression as self-directed anger. As a result of this decision, Beck endured isolation and rejection from many in the psychiatric community for many years. Through his research, Beck developed a cognitive theory of depression, which represents one of the most comprehensive conceptualizations. He found the cognitions of depressed persons to be characterized by errors in logic that he called “cogni- tive distortions.” For Beck, negative thoughts reflect underlying dysfunctional beliefs and assumptions. When these beliefs are triggered by situational events, a depressive pattern is put in motion. Beck believes clients can assume an active role in modif ying their dysfunctional thinking and thereby gain relief from a range of psychiatric conditions. His continuous research in the areas of psychopathology and the utility of cognitive therapy has earned him a place of prominence in the scientific community in the United States. Beck joined the Department of Psychiatry of the University of Pennsylvania in 1954, where he cur- rently holds the position of Professor (Emeritus) of Psychiatry. Beck’s pioneering research established the ef ficacy of cognitive therapy for depression. He has successfully applied cognitive therapy to depres- sion, generalized anxiety and panic disorders, suicide, alcoholism and drug abuse, eating disorders, marital and relationship problems, psychotic disorders, and personality disorders. He has developed assessment scales for depression, suicide risk, anxiety, self-con- cept, and personality. He is the founder of the Beck Institute, which is a research and training center directed by one of his four children, Dr. Judith Beck. He has eight grandchildren and has been married for more than 50 years. To his credit, Aaron Beck has focused on developing the cognitive therapy skills of hundreds of clinicians throughout the world. In turn, they have established their own cogni- tive therapy centers. Beck has a vision for the cognitive therapy community that is global, inclusive, collabora- tive, empowering, and benevolent. He continues to be active in writing and research; he has published 17 books and more than 450 articles and book chapters (Padesky, 2006). For more on the life of Aaron T. Beck, see Aaron T. Beck (Weishaar, 1993). A A R O N T . B E C K Co ur te sy o f B ec k In st it ut e fo r C og ni ti ve Th er ap y an d Re se ar ch B al a Cy nw yd , P A therapy (CBT). Cognitive behavior therapy, which combines both cognitive and behavioral principles and methods in a short-term treatment approach, has generated more empirical research than any other psychotherapy model (Dattilio, 2000a). All of the cognitive behavioral approaches share the same basic char- acteristics and assumptions of traditional behavior therapy as described in C H A P T E R T E N k Cog n it i ve B ehav ior T herap y 275 Chapter 9. As is true of traditional behavior therapy, the cognitive behavioral approaches are quite diverse, but they do share these attributes: (1) a collab- orative relationship between client and therapist, (2) the premise that psycho- logical distress is largely a function of disturbances in cognitive processes, (3) a focus on changing cognitions to produce desired changes in affect and behavior, and (4) a generally time-limited and educational treatment focusing on specifi c and structured target problems (Arnkoff & Glass, 1992; Weishaar, 1993). All of the cognitive behavioral therapies are based on a structured psy- choeducational model, emphasize the role of homework, place responsibility on the client to assume an active role both during and outside of the therapy sessions, and draw from a variety of cognitive and behavioral strategies to bring about change. To a large degree, cognitive behavior therapy is based on the assumption that a reorganization of one’s self-statements will result in a corresponding re- organization of one’s behavior. Behavioral techniques such as operant condi- tioning, modeling, and behavioral rehearsal can also be applied to the more subjective processes of thinking and internal dialogue. The cognitive behavioral approaches include a variety of behavioral strategies (discussed in Chapter 9) as a part of their integrative repertoire. Albert Ellis’s Rational Emotive Behavior Therapy Rational emotive behavior therapy (REBT) was one of the fi rst cognitive be- havior therapies, and today it continues to be a major cognitive behavioral ap- proach. REBT has a great deal in common with the therapies that are oriented toward cognition and behavior as it also stresses thinking, judging, deciding, analyzing, and doing. The basic assumption of REBT is that people contribute to their own psychological problems, as well as to specifi c symptoms, by the way they interpret events and situations. REBT is based on the assumption that cognitions, emotions, and behaviors interact signifi cantly and have a reciprocal cause-and-effect relationship. REBT has consistently emphasized all three of these modalities and their interactions, thus qualifying it as an integrative ap- proach (Ellis, 1994, 1999, 2001a, 2001b, 2002, 2008; Ellis & Dryden, 1997; Wolfe, 2007). Ellis argued that the psychoanalytic approach is sometimes very ineffi - cient because people often seem to get worse instead of better (Ellis, 1999, 2000, 2001b, 2002). He began to persuade and encourage his clients to do the very things they were most afraid of doing, such as risking rejection by signifi cant others. Gradually he became much more eclectic and more active and directive as a therapist, and REBT became a general school of psychotherapy aimed at providing clients with the tools to restructure their philosophical and behav- ioral styles (Ellis, 2001b; Ellis & Blau, 1998). Although REBT is generally conceded to be the parent of today’s cogni- tive behavioral approaches, it was preceded by earlier schools of thought. Ellis acknowledges his debt to the ancient Greeks, especially the Stoic philosopher 276 PA R T T WO k T he or ie s a nd Te c h n iq ue s of Cou n s el i ng Epictetus, who said around 2,000 years ago: “People are disturbed not by events, but by the views which they take of them” (as cited in Ellis, 2001a, p. 16). Ellis contends that how people disturb themselves is more comprehensive and pre- cise than that: “People disturb themselves by the things that happen to them, and by their views, feelings, and actions” (p. 16). Karen Horney’s (1950) ideas on the “tyranny of the shoulds” are also apparent in the conceptual framework of REBT. Ellis also gives credit to Adler as an infl uential precursor. As you will re- call, Adler believed that our emotional reactions and lifestyle are associated with our basic beliefs and are therefore cognitively created. Like the Adlerian approach, REBT emphasizes the role of social interest in determining psycho- logical health. There are other Adlerian infl uences on REBT, such as the impor- tance of goals, purposes, values, and meanings in human existence. REBT’s basic hypothesis is that our emotions stem mainly from our be- liefs, evaluations, interpretations, and reactions to life situations. Through the therapeutic process, clients learn skills that give them the tools to identify and dispute irrational beliefs that have been acquired and self-constructed and are now maintained by self-indoctrination. They learn how to replace such ineffec- tive ways of thinking with effective and rational cognitions, and as a result they change their emotional reactions to situations. The therapeutic process allows clients to apply REBT principles of change not only to a particular presenting problem but also to many other problems in life or future problems they might encounter. Several therapeutic implications fl ow from these assumptions: The focus is on working with thinking and acting rather than primarily with expressing feelings. Therapy is seen as an educational process. The therapist functions in many ways like a teacher, especially in collaborating with a client on homework assignments and in teaching strategies for straight thinking; and the client is a learner, who practices the newly learned skills in everyday life. REBT differs from many other therapeutic approaches in that it does not place much value on free association, working with dreams, focusing on the cli- ent’s past history, expressing and exploring feelings, or dealing with transfer- ence phenomena. Although transference and countertransference may sponta- neously occur in therapy, Ellis (2008) claimed “they are quickly analyzed, the philosophies behind them are revealed, and they tend to evaporate in the pro- cess” (p. 209). Furthermore, when a client’s deep feelings emerge, “the client is not given too much chance to revel in these feelings or abreact strongly about them” (p. 209). Ellis believes that such cathartic work may result in clients feel- ing better, but it will rarely aid them in getting better. Key Concepts View of Human Nature Rational emotive behavior therapy is based on the assumption that human beings are born with a potential for both rational, or “straight,” thinking and irrational, or “crooked,” thinking. People have predispositions for self- preservation, happiness, thinking and verbalizing, loving, communion with C H A P T E R T E N k Cog n it i ve B ehav ior T herap y 277 others, and growth and self-actualization. They also have propensities for self- destruction, avoidance of thought, procrastination, endless repetition of mis- takes, superstition, intolerance, perfectionism and self-blame, and avoidance of actualizing growth potentials. Taking for granted that humans are fallible, REBT attempts to help them accept themselves as creatures who will continue to make mistakes yet at the same time learn to live more at peace with them- selves. View of Emotional Disturbance REBT is based on the premise that although we originally learn irrational be- liefs from signifi cant others during childhood, we create irrational dogmas by ourselves. We do this by actively reinforcing self-defeating beliefs by the processes of autosuggestion and self-repetition and by behaving as if they are useful. Hence, it is largely our own repetition of early-indoctrinated irrational thoughts, rather than a parent’s repetition, that keeps dysfunctional attitudes alive and operative within us. Ellis contends that people do not need to be accepted and loved, even though this may be highly desirable. The therapist teaches clients how to feel undepressed even when they are unaccepted and unloved by signifi cant others. Although REBT encourages people to experience healthy feelings of sadness over being unaccepted, it attempts to help them fi nd ways of over- coming unhealthy feelings of depression, anxiety, hurt, loss of self-worth, and hatred. Ellis insists that blame is at the core of most emotional disturbances. There- fore, to recover from a neurosis or a personality disorder, we had better stop blaming ourselves and others. Instead, it is important that we learn to fully accept ourselves despite our imperfections. Ellis (Ellis & Blau, 1998; Ellis & Harper, 1997) hypothesizes that we have strong tendencies to escalate our de- sires and preferences into dogmatic “shoulds,” “musts,” “oughts,” demands, and commands. When we are upset, it is a good idea to look to our hidden dogmatic “musts” and absolutist “shoulds.” Such demands create disruptive feelings and dysfunctional behaviors (Ellis, 2001a, 2004a). Here are three basic musts (or irrational beliefs) that we internalize that in- evitably lead to self-defeat (Ellis, 1994, 1997, 1999; Ellis & Dryden, 1997; Ellis & Harper, 1997): • “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, 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. If I don’t get what I want, it’s terrible, and I can’t stand it.” We have a strong tendency to make and keep ourselves emotionally disturbed by internalizing self-defeating beliefs such as these, which is why it is a real challenge to achieve and maintain good psychological health (Ellis, 2001a, 2001b). 278 PA R T T WO k T he or ie s a nd Te c h n iq ue s of Cou n s el i ng A-B-C Framework The A-B-C framework is central to REBT theory and practice. This model provides a useful tool for understanding the client’s feelings, thoughts, events, and behavior (Wolfe, 2007). A is the existence of a fact, an activating event, or the behavior or at- titude of an individual. C is the emotional and behavioral consequence or reaction of the individual; the reaction can be either healthy or unhealthy. A (the activat- ing event) does not cause C (the emotional consequence). Instead, B, which is the person’s belief about A, largely causes C, the emotional reaction. The interaction of the various components can be diagrammed like this: A (activating event) ← B (belief) → C (emotional and behavioral consequence) ↑ D (disputing intervention) → E (effect) → F (new feeling) If a person experiences depression after a divorce, for example, it may not be the divorce itself that causes the depressive reaction but the person’s beliefs about being a failure, being rejected, or losing a mate. Ellis would maintain that the beliefs about the rejection and failure (at point B) are what mainly cause the depression (at point C) —not the actual event of the divorce (at point A). Believ- ing that human beings are largely responsible for creating their own emotional reactions and disturbances, showing people how they can change their irratio- nal beliefs that directly “cause” their disturbed emotional consequences is at the heart of REBT (Ellis, 1999; Ellis & Dryden, 1997; Ellis, Gordon, Neenan, & Palmer, 1997; Ellis & Harper, 1997). How is an emotional disturbance fostered? It is fed by the self-defeating sentences clients continually repeat to themselves, such as “I am totally to blame for the divorce,” “I am a miserable failure, and everything I did was wrong,” “I am a worthless person.” Ellis repeatedly makes the point that “you mainly feel the way you think.” Disturbed emotional reactions such as depres- sion and anxiety are initiated and perpetuated by clients’ self-defeating belief systems, which are based on irrational ideas clients have incorporated and in- vented. The revised A-B-Cs of REBT now defi ne B as believing, emoting, and behaving. Because belief involves strong emotional and behavioral elements, Ellis (2001a) added these latter two components to the A-B-C model. After A, B, and C comes D (disputing). Essentially, D is the application of methods to help clients challenge their irrational beliefs. There are three components of this disputing process: detecting, debating, and discriminat- ing. First, clients learn how to detect their irrational beliefs, particularly their absolutist “shoulds” and “musts,” their “awfulizing,” and their “self-downing.” Then clients debate their dysfunctional beliefs by learning how to logically and empirically question them and to vigorously argue themselves out of and act against believing them. Finally, clients learn to discriminate irrational (self- defeating) beliefs from rational (self-helping) beliefs (Ellis, 1994, 1996). Cogni- tive restructuring is a central technique of cognitive therapy that teaches peo- ple how to improve themselves by replacing faulty cognitions with constructive beliefs (Ellis, 2003). Restructuring involves helping clients learn to monitor their self-talk, identify maladaptive self-talk, and substitute adaptive self-talk for their negative self-talk (Spiegler, 2008). C H A P T E R T E N k Cog n it i ve B ehav ior T herap y 279 Ellis (1996, 2001b) maintains that we have the capacity to signifi cantly change our cognitions, emotions, and behaviors. We can best accomplish this goal by avoiding preoccupying ourselves with A and by acknowledging the futility of dwelling endlessly on emotional consequences at C. Rather, we can choose to examine, challenge, modify, and uproot B—the irrational beliefs we hold about the activating events at A. Although REBT uses many other cognitive, emotive, and behavioral meth- ods to help clients minimize their irrational beliefs, it stresses the process of disputing (D) such beliefs both during therapy sessions and in everyday life. Eventually clients arrive at E, an effective philosophy, which has a practical side. A new and effective belief system consists of replacing unhealthy thoughts with healthy ones. If we are successful in doing this, we also create F, a new set of feelings. Instead of feeling seriously anxious and depressed, we feel health- ily sorry and disappointed in accord with a situation. In sum, philosophical restructuring to change our dysfunctional personality involves these steps: (1) fully acknowledging that we are largely responsible for creating our own emotional problems; (2) accepting the notion that we have the ability to change these disturbances signifi cantly; (3) recognizing that our emotional problems largely stem from irrational beliefs; (4) clearly perceiving these beliefs; (5) seeing the value of disputing such self-defeating beliefs; (6) accepting the fact that if we expect to change we had better work hard in emotive and behavioral ways to counteract our beliefs and the dys- functional feelings and actions that follow; and (7) practicing REBT methods of uprooting or changing disturbed consequences for the rest of our life (Ellis, 1999, 2001b, 2002). The Therapeutic Process Therapeutic Goals According to Ellis (2001b; Ellis & Harper, 1997), we have a strong tendency not only to rate our acts and behaviors as “good” or “bad,” “worthy” or “unworthy,” but also to rate ourselves as a total person on the basis of our performances. These ratings constitute one of the main sources of our emotional disturbances. Therefore, most cognitive behavior therapists have the general goal of teaching clients how to separate the evaluation of their behaviors from the evaluation of themselves—their essence and their totality—and how to accept themselves in spite of their imperfections. The many roads taken in rational emotive behavior therapy lead toward the destination of clients minimizing their emotional disturbances and self- defeating behaviors by acquiring a more realistic and workable philosophy of life. The process of REBT involves a collaborative effort on the part of both the therapist and the client in choosing realistic and self-enhancing therapeutic goals. The therapist’s task is to help clients differentiate between realistic and unrealistic goals and also self-defeating and self-enhancing goals (Dryden, 2002). A basic goal is to teach clients how to change their dysfunctional emo- tions and behaviors into healthy ones. Ellis (2001b) states that two of the main goals of REBT are to assist clients in the process of achieving unconditional self- acceptance (USA) and unconditional other acceptance (UOA), and to see how these 280 PA R T T WO k T he or ie s a nd Te c h n iq ue s of Cou n s el i ng are interrelated. As clients become more able to accept themselves, they are more likely to unconditionally accept others. Therapist’s Function and Role The therapist has specifi c tasks, and the fi rst step is to show clients how they have incorporated many irrational “shoulds,” “oughts,” and “musts.” The ther- apist disputes clients’ irrational beliefs and encourages clients to engage in ac- tivities that will counter their self-defeating beliefs and to replace their rigid “musts” with preferences. A second step in the therapeutic process is to demonstrate how clients are keeping their emotional disturbances active by continuing to think il- logically and unrealistically. In other words, because clients keep reindoc- trinating themselves, they are largely responsible for their own personality problems. To get beyond mere recognition of irrational thoughts, the therapist takes a third step—helping clients modify their thinking and minimize their ir- rational ideas. Although it is unlikely that we can entirely eliminate the tendency to think irrationally, we can reduce the frequency. The therapist confronts clients with the beliefs they originally unquestioningly accepted and demonstrates how they are continuing to indoctrinate themselves with unexamined assumptions. The fourth step in the therapeutic process is to challenge clients to develop a rational philosophy of life so that in the future they can avoid becoming the victim of other irrational beliefs. Tackling only specifi c problems or symptoms can give no assurance that new illogical fears will not emerge. It is desirable, then, for the therapist to dispute the core of the irrational thinking and to teach clients how to substitute rational beliefs and behaviors for irrational ones. The therapist takes the mystery out of the therapeutic process, teaching clients about the cognitive hypothesis of disturbance and showing how faulty beliefs lead to negative consequences. Insight alone does not typically lead to personality change, but it helps clients to see how they are continuing to sabo- tage themselves and what they can do to change. Client’s Experience in Therapy Once clients begin to accept that their beliefs are the primary cause of their emotions and behaviors, they are able to participate effectively in the cogni- tive restructuring process (Ellis et al., 1997; Ellis & MacLaren, 1998). Because psychotherapy is viewed as a reeducative process, clients learn how to apply logical thought, participate in experiential exercises, and carry out behavioral homework as a way to bring about change. Clients can realize that life does not always work out the way that they would like it to. Even though life is not always pleasant, clients learn that …