Brief Intervention Strategies
Ellis (2001b) stated that "REBT was specifically designed from the start to be brief but effective for many (not all) clients" (p. 125). Although some clients are seriously disturbed and need more extensive therapy, Ellis (2001b) noted that "self-neurolitizing individuals can be significantly helped in five to twelve sessions" (p. 125).
Beginning in the first session, REBT counselor or therapists teach clients the ABCs of emotional disturbance and show them not only how they construct and maintain their symptoms but also how to ameliorate them. This explanation contributes to significant improvement, which Ellis (2001b) maintained can occur in a few weeks.
Perhaps what distinguishes REBT theory from many others and also makes it briefer is that it is a self-help approach; clients are taught how to change their irrational thinking so they can apply this technique to present as well as future problems. In addition, they learn to practice the skills and concepts between sessions by completing various homework assignments, using REI, or using reinforcements and penalties. All these techniques, in addition to those previously described, are brief interventions.
Clients With Serious Mental Health Issues
According to Seligman (2004), there has been an increase in the severity of disorders that counselors and therapists are needing to treat. Among the mental disorders included in Seligman's discussion, REBT has been applied to a wide variety of them, including the treatment of anxiety (Ellis, 2001b; Warren, 1997), depression (Hauck & McKeegan, 1997; Walen & Rader, 1991), obsessive-compulsive disorder (OCD; Ellis, 1997), panic disorder and agoraphobia (Yankura, 1997), schizophrenia (Trower, 2003), and borderline personality disorder (Ellis, 2001b). A brief description of REBT applications to these disorders follows.
From an REBT perspective, clients with generalized anxiety disorder are more likely to "interpret ambiguous information as threatening, overestimate the probability of the occurrence of potentially dangerous events, and rate the feared events as more aversive or costly" (Warren, 1997, p. 14). Furthermore, these clients may have issues related to approval and self-worth, or fear criticism and worry about making mistakes, which makes many life circumstances appear threatening.
After assessing the irrational beliefs, REBT practitioners would lead clients through the disputation process, paying special attention to their anxiety about being anxious ("I can't stand this, I shouldn't be anxious"), and also noting the shame and self-downing that clients often experience about their worry and anxiety (Walen & Rader, 1991). Teaching clients to differentiate between the possibility of something occurring and the probability of it happening is also an effective strategy.
Ellis (2001b) maintained that REBT is an effective therapy with clients who are depressed because it specifically focuses on addressing irrational beliefs as opposed to correcting distorted negative inferences. For this reason, it may result in more pervasive and long- lasting change. According to DiGiuseppe, Doyle, and Rose (2002), clinical depression results when individuals have one or more of the following beliefs: a negative view of self, a negative view of their environment, a bleak view of the future, the predichon that negative things will happen to them, a belief that they must do better and be approved of by significant others, and a belief that they should be treated better in life. The REBT counselor or therapist maintains that these irrational beliefs play a pivotal role in the development, progression, and alleviation of depression (Hauck & McKeegan, 1997) while at the same time acknowledging that depression may also be biological. When depression is primarily biological in origin, a combination of cognitive therapy and antidepressant medication is most likely needed (Wagner, 2004).
Walen and Rader (1991) cautioned that the basic principle of cognitive therapy – how one feels is based on what one thinks – may send an erroneous message to clients with serious depressive illnesses that they are responsible for their illness. These authors strongly suggested that counselors or therapists differentiate among the different types of depression. Furthermore, they stressed the importance of letting clients with acute depression know that they have an illness and help them reframe depression as a disease, not a character flaw.
Ellis (1997) indicated that the need for certainty contributes to individuals' tendency to develop rituals or obsessions but noted that OCD may be the result of biological deficiencies, in which case medication may be needed in combination with REBT procedures. Although techniques such as activity homework and in vivo desensitization are often used successfully with OCD clients, clients with severe OCD are so obsessed with their repetitive behaviors that they find it difficult to adhere to the behavioral, emotive, or cognitive techniques and fail to persist in changing their ritualizing.
Foa and Wilson (1991) identified several important considerations in treating OCD clients, including helping them recognize that the anxieties that underlie their OCD behaviors are unrealistic, illogical, and self-defeating. These authors also stressed the importance of helping clients develop high frustration tolerance so that they can work harder to overcome their repeated rituals. Ellis (1997) pointed out that these clients often put themselves down for having OCD and indicated that REBT counselors or therapists must help these clients accept themselves unconditionally with their OCD and use REBT techniques to help them dispute their anxiety, depression, and self-hatred about having this disorder.
Panic Disorder and Agoraphobia
Some individuals have a biological predisposition to panic disorder as a result of their genetic makeup (Clum, 1990), in which case psychotropic medications are often helpful in reducing symptoms. However, Yankura (1997) stressed that it is not sufficient to treat panic disorders with medication alone, noting that it is far more effective to also use approaches such as REBT that teach coping skills to increase clients' sense of self-efficacy.
The REBT treatment for anxiety disorders "involves helping clients to identify, dispute, and replace the irrational beliefs that underpin their anxiety problems" (Yankura, 1997, p. 126). Typical irrational beliefs include thinking that they must not experience uncomfortable feelings or a panic attack and that something terrible may happen if they do. For example, clients may think it would be awful if they fainted or lost control and that they could not stand the embarrassment. It follows, then, that clients would tend to avoid going to places where they have had a panic attack, which results in their agoraphobia. These clients also tend to put themselves down, thinking they should be better able to control the panic and avoidant behavior, and they are weak and inadequate if they cannot.
The REBT counselor or therapist uses a number of interventions, including helping clients distribute their catastrophizing and awfulizing about their anxiety and teaching them how to use distraction techniques by focusing on their breathing or tensing and relaxing muscles (Clum, 1990). Clients can also use an approach called flooding, in which they confront what they fear (Yankura, 1997).
Borderline Personality Disorder
According to Ellis (2001b), people with borderline personality disorder seem "to be bom with innate tendencies that interact with their experience to produce several deficiencies" (p. 362). They have rigid and impulsive thinking styles, have inconsistent images of others, exaggerate the significance of things, are demanding and self-downing and easily enraged, in addition to being overdependent and often alienated (Cloninger, 2000, cited in Ellis, 2001b). Ellis (2001b) maintained that individuals with borderline personality disorders have high levels of self-downing and low frustration tolerance. Although it is possible to help them minimize their disturbing themselves about their condition, the reality is that they can rarely be completely cured. However, Ellis (2001b) maintained that improvement can be achieved by using REBT to teach clients how to unconditionally accept themselves, how to ameliorate the self-defeating nature of their low frustration tolerance, and how to challenge their dysfunctional cognitions.
Rational emotive behavior therapy has been implemented cross-culturally for years through the Albert Ellis Institute affiliated training centers located throughout the world. In these centers, counselors and therapists receive training and supervision in using this theory with clients. Consequently, REBT is widely used in many different countries.
Ellis (2002b) stressed that counselors and therapists should be multiculturally open- minded, knowing as much as possible about the rules of other cultures. He emphasized that REBT practitioners are "almost intrinsically multicultural" (p. 195) in that they accept all clients unconditionally, regardless of their cultural, religious, or political practices. He also pointed out that oppression exists in most cultures and that teaching clients this unconditional other-acceptance might help diminish depression.
In more recent years, Ellis (2002b) abandoned his theory that religion and spirituality did more harm than good, acknowledging that devout faith is not irrational and self- defeating. In fact, he admitted that faith has resulted in many emotional-behavioral benefits for individuals.
Lega and Ellis (2001) initiated some cross-cultural studies, noting that this is an important new direction for REBT research. These authors found that the concepts of musts and demandingness apply to several different Latin American and European cultures but vary somewhat in degree. Ellis hypothesized that cultural and biological factors influence how these differences are manifested. He and Lega recommended increasing emphasis on multicultural research, which would in him promote more informed practice of the theory in different cultures.