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Dr. Mike Abrams and Dr. Albert Ellis
British Journal of Guidance & Counselling; Feb94, Vol. 22 Issue
RATIONAL EMOTIVE BEHAVIOR THERAPY IN THE TREATMENT OF STRESS
ABSTRACT Rational emotive behavior therapists view stress-related
disorders as originating in irrational beliefs (iB's), philosophies and
attitudes, as opposed to the stressor. People who suffer from stress
differ from people who suffer from emotional or neurotic problems mainly
in that the stressed people have iB's about specific, short-term or more
readily identifiable events, as opposed to the more mundane and diffuse
difficulties suffered by the neurotic individual. Both the conscious and
unconscious antecedents to stress difficulties and how they relate to
distorted thinking and psychophysiological disorders are discussed from
an information-processing perspective. Rational emotive behaviour
treatments for stress-related disorders are detailed and explained.
Introduction
When mental health professionals examine stress as an object of
treatment, we are really talking about the distress, both physical and
emotional, that ensues from a series of interpersonal and environmental
irritants, or a particularly compelling one. The term `stress' is a
broad or generic term applying to many different states and situations
that act on the psyche and body to reduce homeostasis (Elliot &
Einsdorfer, 1982). The lack of a consistent definition of stress makes
any discussion of treatment difficult. After all, stress is not always
bad. Yerkes & Dodson demonstrated this over a generation ago.
Stress-related arousal frequently serves to enhance performance. In
clinical work we typically use the term to apply to those pressures and
strains of living that reduce the quality of life, and require changes
in the individual to restore homeostasis. We shall also use the term to
represent the result of several kinds of dysfunctional or irrational
thinking.
Does `stress' exist?
The key issue for the rational emotive behaviour therapist is: how does
the environmental irritation become oppressive? The answer is largely
found within the stressed individual, not in the events. It is quite
clear that the very same event will produce physiological or emotional
arousal in one set of individuals and virtually no reaction in others.
How then do the dysfunctional emotional and physical states that we call
stress come about?
The answer is simple: stress does not exist. There is no iconoclasm
intended here. We mean it quite literally: stress does not exist in
itself. Stress is like good or evil: it exists only in its perceptions
and reactions of the beholder (or the stressee). To quote Shakespeare:
Hamlet: Why, then 'tis none to you; for there is nothing either good or
bad but thinking makes it so....
The evidence proves the same for stress. There is nothing intrinsically
stressful or assuaging but thinking makes it so (Ellis & Abrahms, 1978).
This is the foundation of the rational emotive behaviour treatment for
stress-related and most emotional disorders (Ellis, 1962). Specifically,
the rational emotive behaviour therapist works to bring the individual
who is quite distressed by events in his or her environment to a state
of mind similar to that of one who does not respond excessively to the
same putative stressors. Only on rare occasions can a therapist help his
or her client by eliminating their problem for them. The therapist is
most effective in changing the client's reaction to the problem, which
will tend to persist despite the best efforts of most clients and
therapists. Specifically, the REBT therapist will seek first and
pre-eminently to change the client's philosophies, attitudes and beliefs
which lead to disturbance.
Stress v. other disturbances
Those who react to activating events (A's) with severe stress differ
from those who have other disturbances in several key ways. First,
stress tends to be more associated with physical illnesses or symptoms
than do other psychological reactions. Second, stress reactions tend to
be based on a single `catastrophic' event or a group of noxious events
that linger over time. This is in contrast to someone who suffers from,
for example, chronic anxiety in which there tend to be a large array of
activating events that ultimately lead to anxiety. In REBT terms, in
stress reactions the A's are often more salient in the formula than the
B's (the person's beliefs). This is particularly true of a particular
kind of stress, post-traumatic stress disorder (PTSD), where the A's are
so stark, unpredictable and harmful (such as rape, incest, or torture)
that a large percentage of `normal' people, who would take less noxious
events in good stride, tend to upset themselves severely and bring on
terrifying flashbacks and nightmares for a period of years (Warren et
al., 1989, 1990; Ellis, 1993).
Thus people with generalised anxiety require very little in the way of
activating events (A's) to perpetuate their anxiety: their own
compelling belief system about possible A's is usually sufficient. In
contrast, the person suffering from a stress reaction can usually point
to some objectively bad events that are the impetus of his or her
malaise. This has the disadvantage of reinforcing the apparent
connection between the A and the C. The stressed individual will
conclude that `my job is giving me an ulcer', or `my husband's temper is
giving me these migraines', and so on. As we will show later on, one
prime goal of rational emotive behaviour therapy is to demonstrate to
the client that the activating event does not by itself cause his or her
psychological or psychophysiological consequence: his or her beliefs
about the event do!
Physiological and psychological reactions
Irrational beliefs and self-defeating styles are the essential origin of
stress (Decker et al., 1982; Vestre & Burnis, 1987; Forman et al.,
1987). However, the individual's particular reaction to stress tends to
be constitutional. Let us examine for a moment the psychophysiological
disorders that develop or worsen as a direct result of stress. These
include digestive system ulcers, hypertension, migraine and tension
headaches, lower back pain, temporo-mandibular joint syndrome, sciatica,
lupus, multiple sclerosis, and others. We do not suggest that there is a
linear correspondence between these stress-related illnesses and
irrational beliefs. Rather, we have found that irrational beliefs are
the foundation of the prolonged arousal and the emotional anguish that
has been shown to be the prime cause of most ills associated with stress
(Larbig, 1978; Woods & Lyons, 1990; Hart et al., 1991).
The process by which irrational beliefs lead to psychophysiological
disorders closely follows Selye's general adaption syndrome. The process
begins with some activating event in the person's environment. The
person then either consciously or unconsciously evaluates this event as
good, bad, dangerous, or unjust, based on his or her belief systems. At
this point there follows arousal of the autonomic nervous system. With
continued arousal, the weakest systems in the body begin to break down.
The unconscious aspects of this process also makes stress disorders more
difficult to treat than those disorders in which there is a reaction to
an overt problem.
REBT and the cognitive psychology of stress
Since REBT is a cognitive-behavioural therapy, let us clarify what we
mean by `unconscious'. We do not refer to any dynamism (such as the id
or the superego) taking direct action or direct control of behaviour.
Instead we refer to several cognitive processes that are rapid and
require minimal capacity. This principle was set forth by Donald
Broadbent more than 35 years ago. He described the mind as a processing
system with a limited capacity. That is, we can perceive only a small
portion of what we sense, and we can consciously apprehend less than
that. Just as we cannot be aware of all the external stimuli to which we
are continually exposed, we cannot be simultaneously aware of all of our
internal information.
The vast array of experiments utilising priming methods and implicit
learning methods demonstrate that we are not always at one with our
mental data base. Priming experiments reveal that our memorial stores
can become activated without our awareness (Scarborough et al., 1979;
Jacoby & Dallas, 1981; Jacobs & Nadel, 1985). Implicit learning and
memory experiments have shown that humans can acquire complex
information without any knowledge of having done so (Abrams & Reber,
1988; Reber, 1989). Other cognitive processes that are not always
accessible to consciousness are attitudes, biases, schemata, and scripts
that are quiescent and unconscious until activated. At that time they
influence consciousness rapidly and indirectly, but they are not
independent of will. With effort they can be ascertained and, if
appropriate, disputed, and replaced with new attitudes, scripts and
schemata.
Kahneman et al. (1982) demonstrated that most of us form judgements
based on what may be faulty heuristics. They further warned that our
acquisition of these heuristics may be involuntary. They and their
co-workers have failed to show, however, that if a person is made aware
that he or she is making judgements based on a faulty heuristic, and is
given an alternative means of making a judgement, he or she will not do
so. In most cases, he or she will.
We all possess these underlying prejudices but are only aware of them if
they are addressed in some fashion. Most people do not think about how
they feel about thin people or fat people until they come upon one of
them. Their unconscious attitudes are not inaccessible but can act
directly on behaviour without directly entering verbal awareness. Other
unconscious cognitive processes involve more specific judgements about
individuals. We frequently make assessments about a person's nature,
beauty or honesty after only a brief view of his or her face. These
assessments, too, tend to be based on unconscious judgements (Lewicki,
1985, 1986). Another important phenomenon is based on the
declarative-procedural-knowledge distinction. This model shows that we
have the ability and knowledge necessary to perform many tasks without
any conscious awareness of having it (Cohen & Squire, 1980; Cohen &
Corkin, 1981; Jacoby & Witherspoon, 1982). In fact, there is research
which indicates that many experts really do not know how they are able
to do what they do so well (Nisbett & Wilson, 1977).
In general, then, what we call unconscious, the experimental
psychologists tend to refer to as those stages of information processing
that occur outside of awareness. In almost all cases these unconscious
processes can be made conscious with effort. A similar process occurs in
somatoform disorders which tend to occur with high frequency among
stress sufferers (Lipowski, 1988; Frost et al., 1988). In these cases
the stressed individual begins to exhibit physical symptoms that cannot
be clearly pinned down. Of course, many people actually become ill, but
are not accurately diagnosed. But those who feel ill without actually
being so, do so because of their own beliefs. One of our clients
exemplifies this.
The case of Gaetano
Gaetano was referred to the clinic of the Institute for Rational-Emotive
Therapy in New York. He had been suffering from severe pains in his neck
and jaw. He had consulted an otolaryngologist and a neurologist as well
as his family physician. Exhaustive medical testing failed to discover
any organic basis for his symptoms.
During therapy Gaetano revealed that he had come from Italy as an
adolescent, and was raised in this country with conservative Italian
values. He eventually did quite well as a construction manager, and
married an American-born businesswoman. Over time the conflict between
their two cultures began to greatly distress Gaetano. His wife, Gloria,
was `too domineering and too independent'. She came and went as she
pleased, and never accepted his authority as `the man' of the household.
This led him to create an increasingly violent rage that he had great
trouble acknowledging. After a few sessions, he said he had fantasies of
killing her. When asked why he did not simply divorce her, he said he
could not do so.
The house they lived in was where Gaetano had been raised, and the house
his father had died in. To give it up would be both painful and
humiliating. He said he could not stand the idea that Gloria could end
up owning it: this would be a terrible indignity he could not bear. Thus
Gaetano had locked himself into what Miller (1944) called an
avoidance-avoidance conflict. He strongly `needed' to avoid his wife,
but he also `needed' to avoid the hassles inherent in ending his hated
marriage. He began picking up women in bars and sleeping with them in
motels. By doing this he felt he was getting justice for the pain his
wife was putting him through, but in turn he suffered great guilt. So,
feeling trapped, he began to express himself through his neck and jaw
pains.
The process by which his situation was converted to physical symptoms
began with his irrational beliefs. Some of these were:
(1) `I cannot stand to be with Gloria one more moment.'
(2) `I must get rid of her, even if I have to kill her.'
(3) `Wanting to kill my wife makes me a terrible person.'
(4) `I must not lose my house, it would make me a fool.'
(5) `It would be terrible and dangerous if I let my rage show.'
(6) `I must punish her by sleeping with other women.'
(7) `I'm a terrible worthless man for cheating on my wife.'
The irrational beliefs about Gaetano's marriage were like a series of
cur-de-sacs. He was trapped, and his growing rage led to increased
anxiety and physical tension. But two other factors led to the
symptomology, the first being constitutional. Some people appear to
possess the innate tendency to express emotions through physical
symptoms (Templer & Lester, 1974; Suls & Rittenhouse, 1987). This notion
is not new. Alexander (1950) proposed that people with these disorders
have a biological predisposition to bring them on. Gaetano probably had
this tendency: otherwise he would have probably expressed his distress
in more traditional ways.
The second factor was Gaetano's beliefs and feelings about inescapable
catastrophe. He saw this as too terrible to be real, so he literally
denied its existence, and instead focused on a part of his body that was
reacting in a typical way to his stress. The muscle tension in his jaw
and head that commonly accompanies many stress reactions was interpreted
as an illness. The focus on his illness distracted him from, even
relieved him of, the pain of his apparently inescapable dilemma.
Thus when people perceive stressors as being so terrible as to fall
outside the domain of any conceivable life event, they may tend to
dissociate. In REBT terms, psychophysiological and somatoform disorders
often result from extreme awfulising, combined with some additional
irrational beliefs. These beliefs may be to the effect that `something
bad absolutely will happen to me!' or `any physical symptom proves
something terrible is happening to my body!'
Gaetano's therapy focused on three aspects of his difficulty. The first
was the system of beliefs that he was in a terrible situation. He was
helped to see that although his situation was bad, it was far from so
bad as to make life unbearable. He was shown how to increase his
frustration tolerance so that he could `stand' to be with his wife until
a way out of his circumstances could be found.
His second set of irrational beliefs, that he absolutely must not be
enraged and have fantasies of revenge, led to his self-downing. He was
shown that although it would have been preferable for him to accept his
wife's disagreeable ways without rage, he was not a bad person for
feeling enraged. He was also shown that his wife was not the absolutely
bad person he was making her out to be, simply because she differed from
him and because he could no longer tolerate her.
The final aspect of Gaetano's therapy helped him to work on practical
solutions. He was encouraged to tell his wife how he felt and to consult
an attorney. After a couple of painful months of legal and domestic
negotiations, she agreed to a divorce, and he was able to keep the
house. His symptoms vanished.
Irrational beliefs and stress
Rational emotive behaviour therapy (REBT) predicates its treatment of
most neurotic problems on the hypothesis that humans, to varying
degrees, endorse and act on convictions that are self- and
socially-defeating. These partially learned and partly constructed
irrational beliefs lead to a significant portion of psychological
difficulties. There are other factors involved in mental disorders, but
these can only be partially addressed with psychotherapy. The other
causes are genetic, biochemical, and structural. Psychotherapy
indirectly treats these other ailments in the same way that it helps
with other problems of life that are unyielding--by helping people
change what they can change, and accept and endure what they cannot
change.
REBT uses a simple model in its system of therapy: the ABCDE model. The
A refers to an unfortunate activating event in people's lives that
results in a dysfunctional behavioural or emotional reaction. B is the
belief system that largely determines or regulates their response to the
A. C is their disturbed consequence to the A and B. D refers to the
disputing that challenges their irrational disturbance-creating beliefs.
Finally, E is their effective new philosophy that they are encouraged to
adopt.
In most discussions of REBT, the C (consequences) refers to emotional
reactions. However, in the case of stress the C is often organic or
physical symptoms. This is very similar to the model of stress adopted
by the National Academy of Sciences (Dollahite, 1991) which expressed
stress reactions in terms of an xyz model. In their version they refer
to the x as the potential activator, the y as the individual's reactions
to the potential activator, and the z as the consequence of the x's and
y's. The authors also label interactions between the x's and y's as
mediators. These researchers came to the same conclusion that I (AK)
came to in 1955. External events do not by themselves result in
disturbance-whether stress or any other kind. The range of reactions to
unpropitious events is so wide that people's perceptions and evaluations
of these events are the prime mediators of their reaction (Ellis, 1962,
1978, 1985a, 1988, 1991; Ellis & Dryden, 1987).
The cognitive process that facilitates the creation of stress almost
always involves irrational beliefs (Woods, 1987; Vestre & Burnis, 1987;
Forman, 1990; Henry et al., 1991). These have been detailed extensively
in previous articles and books, but briefly they include rigid,
inflexible, and usually unexamined beliefs, personal philosophies and
attitudes that we all possess to varying degrees. These can take the
form of unconditional demands, such as: `I have to be successful!'; `All
people who have hurt me must be severely punished!'; `I absolutely must
be physically competent and healthy or life is terrible!'
Negatively distorted judgements (awfulising) are also efficient stress
producers. Some typical ones are: `It would be awful if I were to lose
this case!'; `I couldn't stand to be fired'; `I am totally worthless if
I lose my business!'
Beliefs based on absolute social needs commonly produce stress
reactions. People create traps for themselves with musts that often
cannot be satisfied: `I must get the respect of or love from all
significant people!'; `Other people must respect my needs!'
Stress reactions to irrational thinking differ in one important way from
other disturbed consequences (C) in that the stressed individual tends
to link a number of irrational conclusions together into an overwhelming
whole. The woman who is vying for a promotion and is asked to produce a
key business report on a near-impossible deadline, all the while seeking
to get home early enough to get her child out of day care, will tend to
experience stress. But let us examine the underlying beliefs and demands
that transform these social pressures into her experience of stress. The
stress process begins with her compelling desire to get the promotion,
which becomes the demand: `I must get a promotion and I will be a total
failure if I blow it!' or `I must get the promotion or I'll never get
anywhere!' Next, she becomes aware of the deadline, and further elevates
her arousal with a belief like: `If I don't get the report in by
tonight, they'll know I'm not competent, and that would be awful!', or
`I'll never get it done right in the time they have given me, and
they'll see what an incompetent person I am!'
Research has provided compelling evidence that complex cognitive
processes, like speech, becomes automatic and extremely rapid with
repetition (Posner & Snyder, 1974). Thus habitual statements, like the
preceding, will at times be subtle and rapid. So it requires effort to
first bring them into awareness and then to practice disputing them once
we clearly see them. Without the effort to understand these irrational
cognitions, we are at their mercy. As noted above, experimental
psychology has demonstrated that many judgments occur rapidly, and
sometimes outside of awareness, and that they often result in emotional
changes (Foster & Grovier, 1978; Kunst-Wilson & Zajonc, 1980; Zajonc,
1984). It is difficult, if not impossible, to physically control these
reactions. But a change in personal philosophy ultimately leads to the
cognitive changes that can bring them under control.
Treatment
Rational emotive behaviour therapy uses a large number of cognitive,
emotive and behavioural techniques to help people who over-react to
stressors and who add to their appropriate feelings of concern,
displeasure, and frustration about these stressors, inappropriate,
self-defeating feelings of severe stress, anxiety, and panic. Thus,
rational emotive behaviour practitioners often use biofeedback and
relaxation techniques (Fried & Golden, 1989; Fried, 1990), hypnosis
(Ellis, 1985b; Stanton, 1989), self-instructional training (Meichenbaum,
1977), meditation and yoga (Benson, 1975; Ellis, 1984; Goleman, 1993),
behavioural exercises (Ellis & Abrahms, 1978) and other methods that
other therapists use.
In addition to these traditional methods, REBT usually includes a number
of special cognitive techniques, especially active-directive disputing
(D) of clients' dysfunctional and irrational beliefs (B). Thus, when a
rational emotive behaviour therapist works with someone suffering from
stress-related disorders, the first step usually involves finding the
events that the client is making stressful. The next critical step
involves finding the beliefs, attitudes and personal philosophies by
which clients convert the perceptions to dysphoria. It is this aspect of
REBT that most tests the skill of the therapist.
Many clients seeking help for stress-related disorders feel trapped by
the events that are distressing them. They typically have strong
convictions in the absolute badness of these happenings. Therapists
therefore need to be sensitive and cautious in challenging these
beliefs. Clients suffering from severe stressors are convinced, either
overtly or implicitly, that these `terrible' things are the direct and
only cause of their problems. Helping them come to see that the things
are indeed bad but that their `terribleness' is largely their own
creation will be resisted unless therapists first establish that they
empathetically accept the clients' suffering as real. Perhaps the worst
thing any therapist can do is to dismiss a particular stressor as
`insignificant' or `minor'. If the client perceives it as monumental,
the therapist had better accept this as the starting point.
The next step is to find the specific beliefs, philosophies, and
attitudes that create stress. This can be accomplished by interviewing
clients about their feelings when they encounter stressors. Once their
disturbed emotions are clarified, the therapist in collaboration with
the client probes for the irrational beliefs and dogmas that create
stress reactions, and shows clients how to actively and forcefully
dispute (D) these beliefs (B).
More specifically, REBT teaches clients how to do the following
disputing:
* Disputing absolute musts: `Why must I always succeed and
experience no unfortunate hassles'? Answer: `I never have to succeed,
though I would very much prefer to do so. I really have to experience
many unfortunate hassles because that is the nature of normal living.
It's too damned bad-but hardly awful or terrible.'
* Disputing I-can't-stand-it-itis: `Where is the evidence that I
can't stand these stressors that are now occurring?' Answer: `Only in my
nutty head! I won't die of them and can be happy in spite of them.
They're not horrible but only bearably painful!'
* Disputing feeling of worthlessness: `Is it true that I am an
inadequate, worthless person if I do not handle stressful conditions
well and even make them worse?' Answer: `No, I am a person who may well
be acting inadequately at this time in this respect but I am never a
totally worthless (or good) person, just a fallible human who is doing
my best to cope with difficult conditions.'
As REBT shows people how to look for their absolutist shoulds, oughts,
and musts, and for their awfulising, can't-stand-it-itis, and
self-downing about the stressors that they experience, it also employs a
number of other cognitive methods that it has invented or adopted to
help people change their dysfunctional thinking for more effective and
less disturbing thinking. Thus it uses reframing, and shows clients how
to find good things in some of the bad things that happen to them and
how to accept the challenge of not upsetting themselves when they are
under unusual stress. It helps them, when they procrastinate or are
addicted to harmful feelings and behaviours, to referent a number of
disadvantages of what they are doing and to forcefully go over them
several times a day, so as to plant them into their consciousness. It
`works out' with clients' coping rational self-statements, particularly
philosophical ones, that they keep using to face some of the worst
stressors and to refuse to upset themselves about. Such as: `Yes, I am
really under great strain right now and there is nothing that I can do
about relieving some of it, but I don't have to eliminate it and I can
lead a reasonable happy life even if these difficulties continue.'
Rational emotive behaviour therapy encourages clients to do cognitive
homework, including the steady filling out of the REBT Self-Help Form
(Sichel & Ellis, 1984). This helps them to find and dispute their
irrational beliefs. It provides them with psychoeducational materials,
such as pamphlets, books, and audiovisual cassettes, that show them how
to use rational-emotive anti-disturbing and problem-solving methods
(Ellis, 1978, 1988; Ellis & Harper, 1975). It encourages them to record
their therapy sessions and to listen to these several times. It pushes
them to learn REBT methods and to teach them to others, so as to implant
them into their own hearts and heads. It shows them how to model
themselves after other individuals who have coped well with stressors.
Rational emotive behaviour therapy always uses a number of
emotive-evocative, dramatic methods to help individuals cope with stress
situations. Thus it teaches them how to use rational-emotive imagery
(Maultsby, 1971), in the course of which they work on their disturbed
feelings when they imagine a very stressful event happening, and change
these to appropriate feelings of sorrow, regret, and frustration. It
encourages them to do its famous shame-attacking exercises (Ellis, 1973,
1988) and learn to deliberately do foolish and ridiculous acts in public
and not to upset themselves or put themselves down when others
disapprove of them for doing these acts. It show them how to create and
use very forceful and dramatic coping statements to change some of their
disturbance-creating thoughts and feelings. It encourages them to
tape-record some of their worst irrational beliefs and to strongly
dispute them on tape, and then let their therapists and other people
listen to their disputations to see how forceful they really are. It
provides them with rational humorous songs and other humorous ways of
interfering with their taking stressors too seriously (Ellis, 1987).
Behaviourally, REBT employs a number of action methods to help people
overcome their overly stressful reactions to the difficulties of their
lives. Thus, it encourages them to use in vivo desensitisation and
exposure methods to overcome some of their irrational fears. It shows
them how they can deliberately stay in poor situations (e.g. remain in a
job where their supervisor is hostile and negative) until they give up
their own feelings of horror and terror-and then decide whether to leave
these situations. It shows them how they can reinforce themselves when
they do REBT homework that they agree to do and penalise themselves when
they fail to do it. It gives them skill training in important areas
where they feel very stressed, so that they will function better and
enjoy themselves more in these areas. Thus it often provides clients
with assertion, communication, relationship, and social skills training.
As usual, then, rational emotive behaviour therapy uses a good number of
cognitive, emotive, and behavioural methods, some of which are special
to REBT, to help people make their lives less stressful and to cope with
stressors that they cannot change. It especially tries to help them push
themselves to improve unpleasant social and environmental situations;
but to unconditionally accept themselves, other people, and the world,
even when unusually stressful conditions persist. As Hauck (1977) points
out, when people are faced with unpleasant situations, they have three
main choices: to change, stay with, or leave them. Whichever of these
choices them make, REBT endeavors to help them accomplish it with a
minimum of stress or emotional disturbance. Severe stressors are often
inevitable; undue stress about them is not.
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