Fundamentals of Rational Emotive Behaviour Therapy: A Training Handbook [3 ed.] 1394198515, 9781394198511

Table of contents :
Cover
Title Page
Copyright Page
Contents
About the author
Introduction
Chapter 1 What you need to know about the theory of REBT to get started
The situational ABC model of REBT
Situations
As
As can be actual events
As can be inferred events
As can be external or internal
As can refer to past, present and future events
The importance of assuming temporarily that A is true
Bs
Flexible and non-extreme attitudes
Flexible attitudes
Rigid and extreme attitudes
Rigid attitudes
Cs
Emotional consequences of attitudes
Behavioural consequences of attitudes
Thinking consequences of attitudes
ABCs interact in complex ways: the principle of psychological interactionism
Summary
Chapter 2 What you need to know about the practice of REBT to get started
The ‘core conditions’
Empathy
Unconditional acceptance
Genuineness
Humour
Therapeutic style
Therapist directiveness in REBT
Therapist activity
The goals of REBT
Attitude change
Inferential change
Behavioural change
Changing actual As and situations
Different types of change within a case
Clients’ goals for change
Tasks in REBT
Your tasks as an REBT therapist
Your client’s tasks
Chapter 3 Teaching the ABCs of REBT
The money model
Correct your client’s errors
Common trainee errors in teaching the money model
Failure to clarify vague emotional statements, thus not distinguishing between HNEs and UNEs
Failure to emphasise the rigid and extreme components of the client’s rigid and extreme attitude in part two
Failure to summarise accurately all the points
Summary
The lateness example
Simpler ways of teaching the ABCs
The brief money model
Brief comparison between a rigid attitude and a flexible attitude
Brief comparison between a self-depreciation attitude and an unconditional self-acceptance attitude
Chapter 4 Distinguishing between healthy and unhealthy negative emotions
HNEs and UNEs: a diagrammatic summary
Adversities at A
Basic attitudes
Emotions
Behaviours and action tendencies
Subsequent thinking
Five approaches to teaching clients the distinction between HNEs and UNEs
Distinguishing between emotional terms (approach 1)
Distinguishing between symptoms (approach 5)
Teaching your client to distinguish between a UNE (unhealthy anger) and an HNE (healthy anger): an illustrative dialogue
Chapter 5 Being specific in the assessment process
Select a nominated problem
Select and assess a specific example of your client’s nominated problem
Chapter 6 Assessing C
Avoid A C language in assessing C
When that happened, how did you feel?
How did you feel about that?
When your client believes that an HNE is unhealthy
When your client’s C is vague
When your client’s C is really an A
When your client’s C is an extended statement
Chapter 7 Assessing A
Identify the theme and its embodiment
The ‘magic question’
Chapter 8 Assessing B
The two-step approach to assessing attitudes
Windy’s review assessment procedure (WRAP)
Chapter 9 Assessing meta-emotional problems
The ABCs of meta-emotional problems
When the meta-emotional problem is the major focus
Chapter 10 Goal-setting
Setting a goal with respect to a specific example of your client’s nominated problem
Steps for effective goal-setting
Setting a goal with respect to your client’s broad problem
Moving from overcoming disturbance to promoting personal development
Chapter 11 Eliciting your client’s commitment to change
Introduction
The cost–benefit analysis form (CBAF)
General principles
Responding to your client’s perceived advantages of the problem and perceived disadvantages of achieving the goal
Using Socratic questions to help your client rethink the perceived advantages of the problem and the perceived disadvantages of the stated goal
Reconsidering the CBAF and asking your client for a commitment to change
Chapter 12 Preparing your client and yourself to examine their attitudes
Helping your client to see the relevance of examining their attitudes as a primary means of achieving their goal
Helping your client to understand what examining attitudes involves
How many of the four rigid/extreme attitudes and their flexible/non-extreme attitudes should you and your client examine?
Help your client to examine their rigid attitude and alternative flexible attitude unless you have a good reason not to
Help your client to examine their rigid attitude and flexible attitude counterpart and at least one of their three extreme attitudes and their non-extreme attitude counterparts
Help your client to examine one of their rigid/extreme attitudes (and flexible/non-extreme attitudes) when session time is at a premium or that is all they can deal with
Chapter 13 Helping your clients to examine their attitudes
The three main arguments
Empirical arguments
Logical arguments
Pragmatic arguments
The choice-based examination method
Using the choice-based examination method with rigid and flexible attitudes
Using the choice-based examination method with extreme and non-extreme attitudes
Use persuasive arguments in the examination process
Teach your children
Which attitude would you like to have been taught?
Use diagrams
Dealing with clients’ doubts, reservations and objections to developing flexible and non-extreme attitudes and letting go of rigid and extreme attitudes
DRO to adopting a flexible attitude and to giving up a demand
DRO to adopting a non-awfulising attitude and to giving up an awfulising attitude
DRO to adopting an attitude of bearability and to giving up an attitude of unbearability
DRO to adopting an unconditional acceptance attitude and to giving up a devaluation attitude
Chapter 14 Helping your clients to strengthen their conviction in their flexible/non-extreme attitudes
Using zigzag techniques with clients
Helping clients to complete a written zigzag form
Helping clients to use a voice recording version of the zigzag technique
Using rational-emotive imagery with clients
How to use REI with clients: Ellis version
How to use REI with clients: Maultsby version
Suggest that your clients teach flexible/non-extreme attitudes to others
Taking action
Help the client to plan to face the adversity
Suggest that the client avoids the use of safety-seeking strategies
Suggest that the client rehearse flexible/non-extreme attitudes at appropriate points during the facing-the-adversity process
Help your client to rehearse their flexible/non-extreme attitude in different ways
Use role-play to rehearse taking action
Help your client to identify and overcome blocks to taking action
The importance of repetition
Chapter 15 Negotiating homework assignments
What’s in a name?
Discussing the purpose of homework assignments
Different types of homework assignments
Cognitive assignments
Imagery assignments
Behavioural assignments
Emotive assignments
The importance of negotiating homework assignments
The ‘challenging, but not overwhelming’ principle of homework negotiation
How to increase the chances that your client will do homework
Teach your client the ‘no-lose’ concept of homework assignments
Ensure that your client has sufficient skills to carry out the homework assignment
Ensure that your client believes that they can do the homework assignment
Give yourself sufficient time to negotiate a homework assignment
Ensure that the homework assignment follows logically from the work you have done with your client in the therapy session
Ensure that your client understands the nature and purpose of the homework assignment
Help your client to specify when, where and how often they will do the homework task
Elicit a firm commitment that your client will carry out the homework assignment
Troubleshoot any obstacles to homework assignment completion
Encourage your client to keep a written note of their homework assignment and relevant details
Rehearse the homework assignment in the therapy room
Use the principle of rewards and penalties to encourage your client to do the homework assignment
Monitor your skills at negotiating homework assignments
Chapter 16 Reviewing homework assignments
Put reviewing your client’s homework assignment on the session agenda
When is it best to review homework assignments?
Important issues to consider when reviewing homework assignments
When your client states that they did the homework assignment, check whether or not it was done as negotiated
Review what your client learnt from doing the homework assignment
Capitalise on your client’s success
Responding to your client’s homework ‘failure’
Dealing with the situation when your client has not done the homework assignment
Chapter 17 Dealing with your clients’ misconceptions of rebt theory and practice
Chapter 18 Using rebt in a single-session therapy format
Introduction
The conventional therapy mindset
Many clients want immediate help
Albert Ellis’s approach to the first session
Key principles of the SST mindset
The importance of informed consent
The practice of REBT in a single-session format
Send the person relevant pre-session information and a questionnaire if practicable and if this is part of your or your agency’s practice
At the beginning of the session, ensure that the person understands the nature of SST
Ask them what help they are looking for from you
Ask them what they want to achieve by the end of the session
Work with the client’s nominated problem, link this with the client’s session goal and keep the focus on these issues
Do an ABC assessment of the specific example of the client’s problem
Help the client to examine their rigid/extreme and flexible/non-extreme attitudes
Suggest that the client rehearse the solution in the session
Help the client to develop an action plan, agree the first steps and deal with potential obstacles
Ask the client to summarise the session
Help the client to specify takeaways and ways to generalise these to other problems
Bring the session to a close and agree access for further help if requested
Get immediate feedback
Carry out a follow-up
Chapter 19 An example of an REBT-based single session
Commentary
Appendix I Homework skills monitoring form
Appendix II Possible reasons for not completing self-help assignments
Appendix III Training in REBT
References
Index
EULA

Citation preview

Fundamentals of Rational Emotive Behaviour Therapy

Fundamentals of Rational Emotive Behaviour Therapy A Training Handbook Third Edition Windy Dryden

This edition first published 2024 © 2024 John Wiley & Sons Ltd Edition History John Wiley & Sons Ltd (1e, 2002; 2e, 2008) All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, ­electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions. The right of Windy Dryden to be identified as the author of this work has been asserted in accordance with law. Registered Offices John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com. Wiley also publishes its books in a variety of electronic formats and by print-­on-­demand. Some content that appears in standard print versions of this book may not be available in other formats. Trademarks: Wiley and the Wiley logo are trademarks or registered trademarks of John Wiley & Sons, Inc. and/or its affiliates in the United States and other countries and may not be used without written permission. All other trademarks are the property of their respective owners. John Wiley & Sons, Inc. is not associated with any product or vendor mentioned in this book. Limit of Liability/Disclaimer of Warranty While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages. Library of Congress Cataloging-in-Publication Data applied for: ISBN: 9781394198511 (paperback); 9781394198535 (ePDF); 9781394198528 (ePub); 9781394198542 (oBook) Cover Design: Wiley Cover Image: © Medesulda/Getty Images Set in 10/13pt Scala and Scala Sans by Straive, Pondicherry, India

Contents

Contents About the author

vii

Introductionix

1 What you need to know about the theory of REBT to get started

1

2 What you need to know about the practice of REBT to get started23 3 Teaching the ABCs of REBT

39

4 Distinguishing between healthy and unhealthy negative emotions53 5 Being specific in the assessment process

71

6 Assessing C75 7 Assessing A

83

8 Assessing B

87

9 Assessing meta-­emotional problems

95

10 Goal-­setting

101

11 Eliciting your client’s commitment to change

113

12 Preparing your client and yourself to examine their attitudes

123

v

Contents

13 Helping your clients to examine their attitudes

127

14 Helping your clients to strengthen their conviction in their flexible/non-­extreme attitudes

141

15 Negotiating homework assignments

153

16 Reviewing homework assignments

173

17 Dealing with your clients’ misconceptions of REBT theory and practice183 18 Using REBT in a single-­session therapy format

193

19 An example of an REBT-­based single session

207

Appendix I: Homework skills monitoring form

219

Appendix II: Possible reasons for not completing self-help assignments

223

Appendix III: Training in REBT

225

References227 Index229

vi

About the author

About the author Windy Dryden is Emeritus Professor of Psychotherapeutic Studies, Goldsmiths University of London. He is a Fellow of the British Psychological Society (BPS) and of the British Association for Counselling and Psychotherapy (BACP). He began his training in REBT in 1977 and became the first Briton to be accredited as an REBT therapist by the Albert Ellis Institute. In 1981, Windy spent a six-­month sabbatical at the Center for Cognitive Therapy, University of Pennsylvania, one of the first British psychologists to do an extended training in cognitive therapy. He is a Fellow of the Albert Ellis Institute and a Founding Fellow of the Academy of Cognitive Therapy. While his primary therapeutic orientation is REBT, Professor Dryden has been very much influenced by his cognitive therapy colleagues, by the working alliance theory of Ed Bordin and by the work by Mick Cooper and John McCleod on pluralism in counselling and psychotherapy. His current interests are in REBT and single-­session therapy. Professor Dryden is perhaps best known for his voluminous writings in REBT/CBT and the wider field of counselling and psychotherapy. He has authored or edited over 265 books, making him one of the most prolific book writers and editors in the field today. He has also edited over 20 book series, including the best-­selling CBT: Distinctive Features series. Professor Dryden was the founding editor in 1982 of the British Journal of Cognitive Psychotherapy, which later merged with the Cognitive Behaviorist to become the Journal of Cognitive Psychotherapy: An International Quarterly. He was co-­founding editor of this journal with E. Thomas Dowd. From 2003 until 2012, he served as editor of the Journal of Rational-­Emotive & Cognitive-­Behavior Therapy. Professor Dryden’s current interests are in providing very brief therapy and coaching for people who need help quickly. In particular, he advocates the use of single-­session therapy as a way of providing help at the point of need.

vii

Introduction

Introduction Having given numerous introductory training courses in rational emotive behaviour therapy (REBT) in Britain and throughout the world, it seemed to me a number of years ago that it would be valuable to write a training handbook on the fundamentals of REBT in which an attempt is made to recreate the atmosphere of these training courses. In particular, because REBT is a simple approach that is difficult to practise well, I wanted to alert trainees to areas of difficulty that they are likely to experience while attempting to use the approach and show them how they can deal constructively with the problems that they will doubtless encounter along the way. To do this, I have used constructed verbatim transcript material between trainees and myself as trainer. What this means is that to highlight trainee difficulty and trainer response, I have constructed dialogues that approximate those that have occurred between myself and trainees over the years. None of these dialogues has actually taken place, however. As I do not record my training sessions, I do not have access to actual trainer–trainee dialogues that have occurred. Nevertheless, the constructed dialogues illustrate the typical errors that trainees make in the practice of REBT. In addition, I will make extensive use of constructed dialogue between myself as therapist and my clients. Please note that on introductory training programmes in REBT, peer counselling is used extensively as a training vehicle. This means that trainees form a pair and take turns counselling one another on real emotional problems and concerns using REBT. In my experience this is a far more effective way of learning how to use REBT and what it feels like to be an REBT client than the use of role-play. To preserve confidentiality, any dialogue that appears in this book between trainees in peer counselling has also been constructed. However, these dialogues are typical of the emotional problems that are raised in this part of the course by trainees in the client role. The performance of REBT trainees in these interchanges approximates the level of skill beginning trainees tend to demonstrate on introductory training courses. It is important to stress that no book on REBT, however practical, can be a substitute for proper training and supervision in the approach. Thus, this book is best used as an adjunct to these educational activities. I have provided information on where to get training and supervision in REBT in Appendix III, should you be interested in pursuing your interest in this therapeutic approach. Indeed, I hope that this handbook might encourage you to attend initial and more advanced training courses in REBT so that you can learn for yourself what it has to offer you and your clients. As I said earlier, this training handbook deals with the fundamentals of REBT practice. As such, I have omitted issues of greater complexity, which may distract you from learning the basics. Let me briefly summarise what I will cover in this volume. In the first two chapters, I outline the basic theoretical and practical information that you need to begin to practise REBT. In the third chapter, I present material on how to teach your clients the ABCs of REBT, while in the fourth chapter, I deal with the important issue of helping your clients to distinguish between healthy and unhealthy negative emotions. In Chapter 5, I stress that when you come to assess your clients’ problems, at the outset it is important to be specific. In Chapters  6,  7 and  8, I show you how to assess C, A and rigid and extreme basic attitudes at B (­previously known as irrational beliefs) respectively. Then, in Chapter 9, I discuss how you can assess

ix

Introduction

your clients’ meta-­emotional problems and when to work with them in therapy. In Chapter 10, I go on to deal with the important issue of helping your clients to set goals, while in Chapter 11, I show you how to build on goal-­setting by encouraging your clients to make a commitment to change. At the heart of REBT is the key task of helping clients to examine their rigid and extreme attitudes, and I devote the next three chapters (Chapters 12–14) to this task. In the next two chapters, I discuss how to negotiate homework assignments with your clients (Chapter 15) and how to review them (Chapter 16). In Chapter 17, I discuss how you can deal with your clients’ misconceptions of REBT theory and practice. In Chapters 18 and 19, I discuss how REBT can inform the practice of single-­session therapy given the fact that the modal number of therapy sessions clients have is ‘1’. Throughout this book I will address you directly as if you are on one of my training courses. Please note that I will use they/them when referring to the gender of the client.

XX A guide to terminology The terminology that I have used in this book to describe salient aspects of REBT theory is a significant departure from the traditional ways that these concepts are described in the REBT literature and I will explain the changes that I have made to traditional REBT language and why I have made them. In Chapter  1 of this book, I will outline REBT’s ABC framework. Traditionally, A has stood for ‘­activating event’, B for ‘beliefs’ and C for the ‘consequences’ of B. This framework outlines the REBT view of psychological disturbance and health. From activating event to adversity In my view, the term ‘activating event’ is problematic because it is not clear what the event activates. REBT theory states that it should activate B, but some people consider that it activates C. Also, the term ‘activating event’ can be taken to mean the event itself or the aspect of the event that the person is most ­disturbed about. REBT states that it should be the latter, but some people consider it to be the former. In this book, I will generally use the term ‘adversity’ to represent the aspect of the situation about which the person is most disturbed, which is what the A in the ABC framework represents. So, the adversity ­activates B that accounts for C. From beliefs to attitudes Traditionally in REBT B has stood for ‘beliefs’, which can either be ‘irrational’ or ‘rational’. I have always been unhappy with these terms and decided formally to change them several years ago (Dryden, 2016). A few years before I took the above decisions, I carried out research on how REBT’s ABC framework is understood by different professional and lay groups.1 This research revealed a range of confusions and errors made by these groups about each element in the framework (Dryden,  2013a), but particularly about B. For example, the term ‘belief’ was often used to describe adversities at A rather than evaluations at B (e.g., ‘I believe that you don’t like me’). I concluded that such confusions and errors about B could be rectified by using the term ‘attitude’ rather than ‘belief’ since the term ‘belief’ is often used by people in a way that is very different from the way it is used in REBT.

1   The four groups were: (a) authors of textbooks on counselling and psychotherapy, (b) REBT therapists, (c) Albert Ellis (when he was in the twilight of his career) and his wife (Ellis & Joffe Ellis, 2011) and (d) patients in a psychiatric hospital who were taught the REBT framework.

x

Introduction

Thus, the term ‘belief’ has been defined by the Oxford Dictionary of Psychology, fourth edition (Colman, 2015) as ‘any proposition that is accepted as true on the basis of inconclusive evidence’. Thus, as we have seen, a client may say something like: ‘I believe my boss criticised me’, and while they think that they have articulated a belief, this is not actually a ‘belief’ as the term has been used in REBT, but rather an inference. It is very important to distinguish between an inference at A and an attitude (or belief in the REBT sense) at B, and anything that helps this distinction to be made routinely is to be welcomed. Using the term ‘attitude’ rather than ‘belief’ in REBT is one way of doing so. Definitions of the term ‘attitude’ are closer to the meaning that REBT theorists ascribe to the term ‘belief’. Here are three such definitions of the term ‘attitude’: ▪▪ ‘an enduring pattern of evaluative responses towards a person, object, or issue’ (Colman, 2015); ▪▪ ‘a relatively enduring organization of beliefs, feelings, and behavioral tendencies towards socially significant objects, groups, events or symbols’ (Hogg & Vaughan, 2005, p. 150); ▪▪ ‘a psychological tendency that is expressed by evaluating a particular entity with some degree of favor or disfavor’ (Eagly & Chaiken, 1993, p. 1). Before deciding to change the term ‘belief’ to the term ‘attitude’ in my writings and clinical work, I used the term ‘attitude’ rather than ‘belief’ with my clients and found that it was easier for me to convey the meaning of B when I used ‘attitude’ than when I used ‘belief’, and they, in general, found ‘attitude’ easier to understand in this context than ‘belief’. Consequently, I decided to use the term ‘attitude’2 instead of the term ‘belief’ to denote an evaluative stance taken by a person towards an adversity at A which has emotional, behavioural and thinking consequences (Dryden, 2016). In deciding to use the term ‘attitude’ rather than the term ‘belief’, I recognise that when it comes to explaining what the B stands for in the ABC framework, the term ‘attitude’ is problematic because it begins with the letter ‘A’. Rather than use an AAC framework, which is not nearly as catchy or as memorable as the ABC framework, I suggested using the phrase ‘basic attitudes’3 when formally describing B in the ABC framework. While not ideal, this term includes ‘attitudes’ and indicates that they are central or basic and that they lie at the base of a person’s responses to an adversity. In using the term ‘basic’, I have thus preserved the letter B so that the well-­known ABC framework can be used. However, when not formally describing the ABC framework I will employ the word ‘attitude’ rather than the phrase ‘basic attitude’ to refer to the particular kind of cognitive processing that REBT argues mediates between an adversity and the person’s responses to that negative event. From ‘irrational’/‘rational’ beliefs to rigid and extreme/flexible and non-­extreme attitudes Another change that I initiated is the movement away from the terms ‘irrational’ and ‘rational’ to the terms ‘rigid and extreme’ and ‘flexible and non-­extreme’ when describing the attitudes that underpin psychological disturbance and psychological health. The reason that I made that change is that the terms ‘irrational’ and ‘rational’ tend to be a turn off to both clients and non-­REBT therapists. Towards the end of his career, Albert Ellis himself regretted that he chose the name ‘rational therapy’ to describe his

2   As this is still a relatively new development, please note that other REBT therapists (including myself in my previous work) still employ the word ‘belief’. 3   This phrase was suggested by my friend and colleague Walter Matweychuk.

xi

Introduction

therapy. He said that he wished that he had called it ‘cognitive therapy’, but he did not do so because the term ‘cognitive’ was not in vogue in the mid-­1950s.4 Clients can see readily that the attitudes that underpin their psychologically disturbed responses to adversities are rigid and extreme. These terms are less pejorative than the term ‘irrational’, which tends to be equated in many clients’ minds with the term ‘crazy’ or the term ‘bizarre’. Far from being seen as something to strive for, the term ‘rational’ is seen by clients as being robot-­like and unemotional. On the other hand, the terms ‘flexible’ and ‘non-­extreme’ when describing the attitudes that underpin psychologically healthy responses to adversities at A are more acceptable to clients. From disputing beliefs to examining attitudes As I mentioned earlier, the ABC framework is used in REBT as an assessment tool to help clients understand the factors involved in their psychologically disturbed responses to adversities and what would constitute psychologically healthy responses to the same adversities. When moving from assessment to therapy, the REBT therapist adds D and E to the ABC framework. Traditionally, D stands for ‘disputing’ beliefs (both irrational and rational) and E stands for the ‘effects’ of the disputing process. I have never cared for the term ‘disputing’. It has an adversarial ‘feel’ about it. It can mean ‘debating’, but it can also mean arguing vehemently. What it does not conjure up is a process where two people stand back and examine the attitudes of one of them. For this reason, I prefer to use the term ‘examining’ when it comes to the therapist and client considering the client’s attitudes (both rigid and extreme and flexible and non-­ extreme). To examine something means to inspect it thoroughly in order to determine its nature or condition. In my opinion, this best approximates what the therapist and client do in what was previously called ‘disputing’. In order to preserve the letter D, I formally use the term ‘dialectically examining attitudes’. The term ‘dialectical’ is particularly apt here since it means trying to resolve a conflict between opposing views, and rigid/extreme and flexible/non-­extreme are opposing ways of evaluating adversities. In general, when not concerned with formalities I will use the term ‘examining attitudes’ to describe the activity more traditionally known as disputing beliefs. See Table 1 for a summary of these changes. Table 1  Terminology employed in this book Traditional REBT language

Language employed in this book

▪▪

Activating event (at A)

▪▪

Adversity (at A)

▪▪

Belief (at B)

▪▪

(Basic) Attitude (at B)

▪▪

Irrational (to describe beliefs)

▪▪

Rigid/extreme (to describe attitudes)

▪▪

Rational (to describe beliefs)

▪▪

Flexible/non-­extreme (to describe attitudes)

▪▪

Disputing beliefs (at D)

▪▪

(Dialectically) Examining attitudes (at D)

I hope that you find this training handbook of use and that it stimulates your interest to develop your skills in REBT. Windy Dryden PhD February, 2023 London and Eastbourne   Interestingly enough, when Ellis changed the name of his therapy from ‘rational therapy’ to ‘rational-­emotive therapy’ in 1962 and to ‘rational emotive behaviour therapy’ in 1993, he had the opportunity to change the ‘rational’ part of the name to ‘cognitive’ but did not do so.

4

xii

What you need to know about the theory of REBT to get started Most books on counselling and psychotherapy begin by introducing you to the theory and practice of the approach in question. This is obviously a sensible way to start such a book because otherwise how are you to understand the practical techniques described by the author(s)? However, in my experience as a reader of such books, I am often given more information than I need about an approach to begin to practise it, at least in the context of a training setting. As I explained in the Introduction, my aim in this training handbook is to recreate the atmosphere of a beginning training seminar in REBT. In such seminars the emphasis is on the acquisition of practical skills and, consequently, theory is kept to a minimum. What I aim to do in such seminars and what I will do in this opening chapter is to introduce the information you will need to know about the theory of REBT so that you can begin to practise it in a training seminar setting. In the following chapter, I will cover what you need to know about the practice of REBT to get started. Let me reiterate a point that I made in the Introduction. When learning any approach to counselling and psychotherapy, you will need to be trained by a competent trainer in the approach you are learning and supervised in your work with clients by a competent supervisor in that approach. To do otherwise is bad and, some would say, unethical practice. Certainly, when learning to practise REBT you will need to be trained and supervised by people competent not only in the practice of REBT but also in educating others how to use it (see Appendix III). A book such as this, then, is designed to supplement not to replace such training and supervision.

W h a t y o u n e e d t o k n o w a b o u t t h e   t h e o r y o f REBT t o g e t s t a r t e d

◀   C HA P TER ONE  ▶

XX The situational ABC model of REBT REBT is one of the cognitive-­behavioural approaches to psychotherapy. This means that it pays particular attention to the role that cognitions and behaviour play in the development and maintenance of people’s emotional problems. However, as I will presently show, REBT argues that at the core of emotional disturbance lies a set of rigid and extreme attitudes1 that people hold towards themselves, other people and the world.

1   As I explained in the Introduction, I prefer to use the word ‘attitudes’ to the word ‘beliefs’ and the terms ‘rigid and extreme a­ ttitudes’ and ‘flexible and non-­extreme attitudes’ to the terms ‘irrational beliefs’ and ‘rational beliefs’. Also, when specifically referring to the B in the ABC framework, I use the term ‘basic attitudes’, as suggested by my friend and colleague Dr Walter Matweychuk, since attitudes lie at the ‘base’ of the person’s reactions at C. However, the rest of the time I use the word ‘attitudes’.

Fundamentals of Rational Emotive Behaviour Therapy: A Training Handbook, Third Edition. Windy Dryden. © 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.

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F U N D A M E N TA L S O F R AT I O N A L E M OT I V E B E H AV I O U R T H E R A P Y

When assessing clients’ psychological problems, REBT therapists employ a situational ABC ­framework, and I will now discuss each element of this framework in turn.

XX Situations In this handbook, you will learn how to help your clients deal with their problems by working with specific examples of these problems. These specific examples occur in specific ‘situations’. Such ‘situations’ are viewed in the ‘situational ABC’ model as descriptions of actual events about which you form inferences (see below). Briefly, inferences go beyond the data at hand and may be accurate or inaccurate. ‘Situations’ exist in time. Thus, they can describe past actual events (e.g., ‘My boss asked me to see her at the end of the day’), present actual events (e.g., ‘My boss is asking me to see her at the end of the day’) or future events (e.g., ‘My boss will ask me to see her at the end of the day’). Note that I have not referred to such future events as future actual events since it is not known that such events will occur (such future events may prove to be false). But if we look at such future ‘situations’, they are still descriptions of what may happen and do not add inferential meaning (see below). ‘Situations’ may refer to internal actual events (i.e., events that occur within ourselves, e.g., thoughts, feelings, bodily sensations, aches and pains, etc.) or to external actual events (i.e., events that occur outside ourselves, e.g., your boss asking to see you). Their defining characteristic is as before: they are descriptions of events and do not include inferential meaning.

XX As As are usually aspects of situations which your client is potentially able to discern and attend to and which can trigger their attitudes at B. While your client is potentially able to focus on different aspects of the situation at any moment, in an ABC episode what I refer to as A represents that actual or psychological event in their life which activates, at that moment, the attitudes that they hold (at B) and which lead to their emotional and behavioural responses (at C). The key ingredient of an A is that it activates or triggers attitudes. An A is usually an aspect of the situation that your client was in when they experienced an emotional response. As have several features that I will explain below. As can be actual events When actual events serve as attitude-­triggering As, they do not contain any inferences that your client adds to the event. While Susan was in therapy, her mother died. She felt very sad about this event and grieved appropriately. Using the ABC framework to understand this, we can say that the death of her mother represented an actual event at A which activated a set of attitudes that underpinned Susan’s grief. As can be inferred events When Wendy was in therapy, her mother died. Like Susan, she felt very sad about this and as such we can say that the death was an actual A, which triggered her sadness-­related attitudes. However, unlike Susan, Wendy also felt guilty in relation to her mother’s death. How can this be explained?

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Returning to the example of Wendy who felt guilty about the death of her mother, I hope you can now see that she is guilty not about the death itself but about some inferred aspect of the death that is significant to her. In this case it emerged that Wendy felt guilty about hurting her mother’s feelings when she was alive. This, then, is an inferred A – it points to something beyond the data available to Wendy; it is personally significant to her and it triggered her guilt-­producing attitude.

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According to REBT, people make interpretations and inferences about the events in their lives. I regard interpretations and inferences as hunches about reality that go beyond observable data which may be correct or incorrect but need to be tested out. While most REBT therapists regard interpretations and inferences to be synonymous, I make the following distinction between them. Interpretations are hunches about reality that go beyond observable data but are not personally significant to the person making them. They are, thus, not implicated in the person’s emotional experience. Inferences are also hunches about reality that go beyond the data at hand, but unlike interpretations they are personally significant to the person making them. They are, then, implicated in the person’s emotional experience. For example, imagine that I am standing with my face to a window and I ask you to describe what I am doing. If you say, ‘You are looking out of the window’, you are making an interpretation in that you are going beyond the data at hand (e.g., I could have my eyes closed) in an area that is probably insignificant to you (i.e., it probably doesn’t matter to you whether I have my eyes open or not) and thus you will not have an emotional response while making the interpretation. However, imagine that in response to my request for you to describe what I was doing in this example, you said, ‘You are ridiculing me’. This, then, is an inference in that you are going beyond the data available to you in an area that is probably significant to you (i.e., it probably matters to you whether or not I am ridiculing you) and thus you will have an emotional response while making the inference. Whether this emotional response is healthy or not, however, depends on the type of attitude you hold about the inferred ridicule.

As can be external or internal So far, I have discussed As that relate to events that have actually happened (e.g., the death of Susan’s mother) or were deemed to have happened (e.g., Wendy’s inference that she hurt her mother’s feelings when she was alive). In REBT, these are known as external events in that they are external to the person concerned. Thus, the death of Susan’s mother is an actual external A and Wendy’s statement that she hurt her mother’s feelings is an inferred external A. However, As can also refer to events that are internal to the person. Such events can actually occur, or their existence can be inferred.

An example of an actual internal event is when Bill experiences a pain in his throat. An example of an inferred internal event is when Bill thinks that this pain means that he has throat cancer. When Bill is anxious in this situation, the inferred internal event (‘I have cancer’) is more likely to trigger his rigid and extreme attitude than the actual internal event (‘I have a pain in my throat’). As such, the inferred internal event is an A2 and the actual internal event is not.

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  In this book, I refer to an A that triggers rigid and extreme attitudes as an adversity.

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As well as bodily sensations, internal As can refer to such phenomena as a person’s thoughts, images, fantasies, emotions and memories. It is important to remember that, as with external As, internal As have their emotional impact by triggering attitudes at B. As can refer to past, present and future events Just as As can be actual or inferred and external or internal, they can also refer to past, present or future events. Before I discuss the time-­dimensional nature of As, remember that the A in an ABC episode, by definition, is that part of the person’s total perceptual field which triggers their attitude at B. When your client’s A in an ABC episode is a past actual event, they do not bring any inferential meaning to this event. Thus, if their father died when they were a teenager, this very event can serve as an A. However, more frequently, particularly in therapy, you will find that your clients will bring inferential meaning to past events. Thus, your client may infer that their father’s death meant that they were deprived in some way or they may infer that his passing away was a punishment for some misdeed that they were responsible for as a child. It is important to remember that it is the inferences your client makes now about a past event that triggers their attitudes at B. Such inferences may relate to the past, present and future.

An example of a future-­related inference that your client might make about an actual past event is as follows: Because my father died when I was a teenager, I will continually look for a father figure to replace him.

I have already discussed present As. However, I do want to stress that your clients can make past-­, present-­or future-­related inferences about present events.

For example, if one of your clients has disturbed feelings about their son coming home late ­(present actual A), they may make the following time-­related inferences about this event that trigger their disturbance-­provoking attitudes: 1. Past-­related inference: ‘He reminds me of the rough kids at school who used to bully me when I was a teenager.’ 2. Present-­related inference: ‘He is breaking our agreement.’ 3. Future-­related inference: ‘If he does this now, he will turn into a criminal.’

The importance of assuming temporarily that A is true As I will show in greater detail in Chapter 7, in order to assess a client’s attitudes accurately you will need to do two things. First, you will need to help your client to identify the A which triggered these attitudes. Because there are many situational aspects that are in your client’s perceptual field, it takes a lot of care and skill to do this accurately. Second, it is important that you encourage your client to assume t­ emporarily that the A is true when it is an inferred A. The reason for doing this is to help your client to identify the 4

Assume temporarily that your client’s A is true when it is an inferred A

XX Bs A major difference between REBT and other approaches to cognitive-­behaviour therapy (CBT) is in the emphasis REBT gives to basic attitudes. In REBT, attitudes are at the base of clients’ emotions and significant behaviours. Such basic attitudes are the only cognitions that constitute the B in the ABC framework in REBT. Thus, while other approaches which use an ABC framework classify all cognitive activity under B, REBT reserves B for basic attitudes and places inferences, for example, under A. It does so because it recognises that it is possible to hold two different types of basic attitudes at B about the same inferred A. It is the type of attitude that determines the nature of the person’s emotional response at C. Let me stress this point because it is very important that you fully grasp it. In REBT, basic attitudes are the only cognitions that constitute B in the ABC framework

XX Flexible and non-­extreme attitudes REBT keenly distinguishes between flexible and non-­extreme attitudes and rigid and extreme attitudes. In this section, I will discuss flexible and non-­extreme attitudes. These have four defining ­characteristics, as shown in Table 1.1. People do not only proceed in life by making descriptions of what they perceive, nor do they just make interpretations and inferences of their perceptions. Rather, we engage in the fundamentally important activity of holding attitudes towards what we perceive and infer. REBT theory posits that people have four types of flexible and non-­extreme attitudes, as shown in Table 1.2.

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attitudes that the A triggered. You may well be tempted to help your client to challenge the inferred A if it is obviously distorted, but it is important for you to resist this temptation if you are to proceed to assess B accurately. This is such an important point that we wish to emphasise it.

Table 1.1  Defining Characteristics of Flexible and Non-­extreme Attitudes ▪▪

Consistent with reality

▪▪

Logical

▪▪

Largely functional in their emotional, behavioural and cognitive consequences

▪▪

Largely helpful to the individual in pursuing their basic goals and purposes

Table 1.2  Four Types of Flexible and Non-­extreme Attitudes ▪▪

Flexible attitudes

▪▪

Non-­awfulising attitudes

▪▪

Attitudes of bearability

▪▪

Unconditional self-­acceptance/other-­acceptance/life-­acceptance attitudes 5

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Flexible attitudes As humans we have a range of preferences, wishes, desires, wants, etc. When we bring a flexible attitude to these preferences, etc., when they are not met then such flexible attitudes are at the base or core of psychological health. Flexible attitudes are often expressed thus: ‘I want to do well in my forthcoming test (‘asserted preference’ component), but I do not have to do so (‘negated demand’ component).’ If only the first part of this flexible attitude was expressed, which I call the ‘asserted preference’ component – ‘I want to do well in my forthcoming test’ – then your client could, implicitly, change this to a rigid attitude or demand – ‘I want to do well in my forthcoming test. . . (and therefore I have to do so).’ Such an attitude is at the base or core of psychological disturbance, as I will describe presently. So, it is important to help your client express fully their flexible attitude, and this involves helping them to include both the ‘asserted preference’ component (i.e., ‘I want to do well in my forthcoming test’) and the ‘negated demand’ component (i.e., ‘but I do not have to do so’).

In short, we have: Flexible attitude = ▪▪ ‘Asserted preference’ component + ▪▪ ‘Negated demand’ component

This flexible attitude is healthy for the following reasons: ▪▪ It is flexible in that your client allows for the fact that they might not do well. ▪▪ It is consistent with reality in that (a) your client really does want to do well in the forthcoming test and (b) there is no law of the universe dictating that they have to do well. ▪▪ It is logical in that both the ‘asserted preference’ component and the ‘negated demand’ component are not rigid and thus the latter follows logically from the former. ▪▪ It will help your client to have immediate functional emotions, behaviours and cognitions and help them pursue their longer-­term goals. Thus, the flexible attitude will motivate them to focus on what they are doing as opposed to how well or badly they are doing it. According to Albert Ellis (1994), the originator of REBT, a flexible attitude is a primary attitude, and three other non-­extreme attitudes are derived from it. These attitudes are non-­awfulising attitudes, attitudes of bearability and unconditional self-­, other-­and life-­acceptance attitudes, and I will deal with each in turn. In doing so, I will emphasise and illustrate the importance of negating the extreme component in formulating a non-­extreme attitude in each of these derivatives. Non-­awfulising attitudes  When your client does not get their preference met and holds a flexible attitude towards this adversity, then it is healthy for them to conclude that it is bad but not awful that they failed to get what they wanted. The more important their preference in this scenario, then the more unfortunate is their failure to get it. Evaluations of badness can be placed on a continuum from 0% to 99.99% badness. However, it is not possible to get to 100% badness. The words of the mother of pop

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Taking my example of the client whose primary flexible attitude is ‘I want to do well in my ­forthcoming test, but I do not have to do so,’ their full non-­awfulising attitude is: ‘It will be bad if I fail to do well in my forthcoming test (‘asserted badness’ component), but it is not awful if I don’t do well (‘negated awfulising’ component).’

If only the first part of this non-­extreme attitude was expressed, which I call the ‘asserted badness’ component – ‘It will be bad if I fail to do well in my forthcoming test’ – then your client could, implicitly, change this to an awfulising attitude, which, as we shall see, REBT theory considers to lead to a disturbed response to the adversity – ‘It will be bad if I fail to do well in my forthcoming test. . . (and therefore it will be awful if I don’t do well).’ So, it is important to help your client express fully their non-­awfulising attitude, and this involves helping them to include both the ‘asserted badness’ component (i.e., ‘It will be bad if I fail to do well in my forthcoming test’) and the ‘negated awfulising’ component (i.e., ‘but it is not awful if I don’t do well’). In short, we have: Non-­awfulising attitude = ▪▪ ‘Asserted badness’ component + ▪▪ ‘Negated awfulising’ component

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singer Smokey Robinson capture this concept quite nicely: ‘From the day you are born till you ride in the hearse, there’s nothing so bad that it couldn’t be worse.’ This should not be thought of as minimising the badness of a very negative event, rather as showing that ‘nothing is truly awful in the universe’.

This non-­awfulising attitude is healthy for the following reasons: ▪▪ It is non-­extreme in that your client allows for the fact that there are things that can be worse than not doing well in the test. ▪▪ It is consistent with reality in that your client really can prove that it would be bad for them not to do well and that it wouldn’t be awful. ▪▪ It is logical in that both the ‘asserted badness’ component and the ‘negated awfulising’ component are non-­extreme and thus the latter follows logically from the former. ▪▪ It will help your client to have immediate functional emotions, behaviours and cognitions and help them pursue their longer-­term goals. Thus, the non-­awfulising attitude will again motivate them to focus on what they are doing as opposed to how well or badly they are doing it. Attitudes of bearability  When your client does not get their preference met and holds a flexible ­attitude towards this adversity, then it is healthy for them to conclude that: 1. It is difficult to bear this adversity. 2. It is not unbearable to do so and they can bear it.

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3. It is worth tolerating (if it is). 4. They are worth bearing the adversity for. 5. They are willing to bear the adversity. 6. They commit themself to bear the adversity. 7. They behaviourally implement this commitment. Adhering to an attitude of bearability enables your client to put up with the frustration of having their goals blocked, and in doing so they are more likely to deal with or circumvent these obstacles so that they can get back on track. REBT holds that the importance of developing an attitude of bearability is that it helps people to pursue their goals, not because bearing frustration is in itself good for people.

Applying this to my example, when your client holds the flexible attitude ‘I want to do well in my forthcoming test, but I do not have to do so,’ their attitude of bearability will be: ‘If I don’t do well in my forthcoming test, that will be difficult to bear (‘asserted struggle’ ­component), but I can stand it. It will not be unbearably intolerable (‘negated unbearability’ component), it is worth it for me to tolerate it (‘worth bearing’ component) and I am worth bearing it for (‘I’m worth bearing it for’ component). Furthermore, I am willing to bear my poor performance (‘willingness to bear it’ component) and I am going to bear it (‘commitment to bear it’ component). Then the person implements this commitment behaviourally (‘behavioural implementation’ component).’

If only the first part of this non-­extreme attitude was expressed, which I call the ‘asserted struggle’ component – ‘If I don’t do well in my forthcoming test, that will be difficult to bear’ – then your client could, implicitly, change this to an attitude of unbearability, which, as we shall see, REBT theory considers to lead to a disturbed response to the adversity – ‘If I don’t do well in my forthcoming test, that will be difficult to bear… (and therefore I can’t stand it if I don’t do well).’ So, it is important to help your client express fully their attitude of bearability, and this involves helping them to include all seven components.

In short, we have: Attitude of bearability = ▪▪ ‘Asserted struggle’ component + ▪▪ ‘Negated unbearability’ component + ▪▪ ‘Worth bearing’ component + ▪▪ ‘I’m worth bearing it for’ component + ▪▪ ‘Willingness to bear it’ component + ▪▪ ‘Commitment to bear it’ component + ▪▪ ‘Behavioural implementation’ component

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▪▪ It is non-­extreme in that the person allows for the fact that not doing well is bearable as opposed to the extreme position that it is unbearable. ▪▪ It is consistent with reality in that the person (a) recognises the struggle involved in bearing the adversity, (b) acknowledges the truth that they really can bear that which is difficult to bear, (c) sees the truth that it is in their interests to bear the adversity (if it is), (d) acknowledges the truth that they are worth bearing it for even if they don’t have a strong conviction in this yet, (e) sees that they have a choice to being willing or, at least, prepared to bear the adversity, (f ) sees the truth that being committed to bear the adversity is better than not being committed to do so and (g) ▪▪ It is logical in that the seven components are all non-­extreme and are thus connected to one another logically. ▪▪ It will help your client to have immediate functional emotions, behaviours and thoughts and help them pursue their longer-­term goals. Thus, it will help them to do well in the sense that it will lead them to focus on what they need to do to face the ‘difficult to bear’ situation of not doing well rather than on the ‘intolerable’ aspects of doing poorly. Unconditional self-­, other-­and life-­acceptance attitudes  In this section, I will focus on unconditional self-­acceptance attitudes. However, the same substantive points apply to unconditional other-­ acceptance attitudes and unconditional life-­acceptance attitudes. When your client does not get their preference met, holds a flexible attitude towards this adversity and this failure can be attributed to themself, then it is healthy for them not to like their behaviour but to accept themselves unconditionally as a fallible human being who has acted poorly. Adopting an attitude of unconditional self-­ acceptance will encourage your client to focus on what needs to be done to correct their own behaviour.

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This attitude of bearability is healthy for the following reasons:

In my example, if your client who holds the flexible attitude ‘I want to do well in my forthcoming test, but I do not have to do so’ fails to do well in this test because of their own failings, then their unconditional self-­accepting attitude will be: ‘I don’t like the fact that I messed up in the test (‘negatively evaluated aspect’ component), but I am not unworthy for my poor performance (‘negated global negative evaluation’ component). Rather, I am a fallible human being too complex to be rated on the basis of my test performance (‘asserted complexity/unrateability/fallibility’ component).’

If only the first two parts of this non-­extreme attitude were expressed, which we call the ‘negatively evaluated aspect’ component – ‘I don’t like the fact that I messed up in the test’ – and the ‘negated global negative evaluation’ component – ‘but I am not unworthy for my poor performance’ – then the person could, implicitly, change this to a self-­devaluation attitude, which (as will be shown later) REBT theory considers an extreme attitude – ‘I don’t like the fact that I messed up in the test, but I am not unworthy for my poor performance (but I would be worthier if I did well than if I did poorly).’ So, it is important to help your client express fully their unconditional self-­acceptance attitude, and this involves helping them to include all three components: the ‘negatively evaluated aspect’ component (‘I don’t like the fact that I messed up in the test’), the ‘negated global negative evaluation’ component (‘but I am not

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unworthy for my poor performance’) and the ‘asserted complexity/unrateability/fallibility’ component (‘Rather, I am a fallible human being too complex to be rated on the basis of my test performance’).

In short, we have: Unconditional acceptance attitude = ▪▪ ‘Negatively evaluated aspect’ component + ▪▪ ‘Negated global negative evaluation’ component + ▪▪ ‘Asserted complex/unrateability/fallibility’ component.

This unconditional self-­acceptance attitude is healthy for the following reasons: ▪▪ It is non-­extreme in that the person sees that they are able to perform well and also poorly. ▪▪ It is consistent with reality in that while the person can prove that they did not do well in the test (remember that at this point we have assumed temporarily that their inferred A is true), they can also prove that they are a fallible human being and that they are not unworthy as a person. ▪▪ It is logical in that the person is not making the part–whole error. They are clear in asserting that the whole of themself is not defined by a part of themself. ▪▪ It will lead to immediate functional emotions, behaviours and thoughts and help them pursue their longer-­term goals. For example, it will help them to do well in the future in the sense that they will be motivated to learn from their previous errors and translate this learning to plan what they need to do to improve their performance in the next test rather than dwell unfruitfully on their past poor performance. Once again let me state that the same points can be made for unconditional other-­acceptance attitudes and unconditional life-­acceptance attitudes.

XX Rigid and extreme attitudes As I mentioned above, REBT keenly distinguishes between flexible and non-­extreme attitudes and rigid and extreme attitudes. Having discussed flexible and non-­extreme attitudes, I will now turn my attention to rigid and extreme attitudes, which lie, according to REBT theory, at the base or core of psychological problems. Rigid and extreme attitudes have four defining characteristics, as shown in Table 1.3. Table 1.3  Defining Characteristics of Rigid and Extreme Attitudes Rigid and extreme attitudes are:

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▪▪

Inconsistent with reality

▪▪

Illogical

▪▪

Largely dysfunctional in their emotional, behavioural and cognitive consequences

▪▪

Largely detrimental to the individual in pursuing their basic goals and purposes

▪▪

Rigid attitudes

▪▪

Awfulising attitudes

▪▪

Attitudes of unbearability

▪▪

Self-­devaluation/Other-­devaluation/Life-­devaluation attitudes

I explained earlier in this chapter that people can have four types of flexible and non-­extreme a­ ttitudes. According to REBT theory, people easily transmute or change these flexible and non-­extreme attitudes into four types of rigid and extreme attitudes (see Table 1.4). Rigid attitudes As humans we often express rigid attitudes in the form of musts, absolute shoulds, demands, have to’s, got to’s, etc. According to REBT, our rigid attitudes are at the core of psychological disturbance.

Taking the example which I introduced above, the rigid attitude is expressed thus: ‘I want to do well in my forthcoming test and therefore I must do so.’ (This is often expressed in everyday life as ‘I must do well in my forthcoming test.’)

Rigid attitudes, like flexible attitudes, are often based on asserted preferences. I have written elsewhere (Dryden, 2021a) that it is difficult for human beings only to think flexibly when their desires are strong. Thus, in my example, if your client’s asserted preference is strong it is easy for them to change it into a rigid attitude: ‘Because I really want to do well in my forthcoming test, therefore I absolutely have to do so.’ As you can see, this attitude has two components: an ‘asserted preference’ component (i.e., ‘I really want to do well in my forthcoming test’) and an ‘asserted demand’ component (‘. . . therefore I absolutely have to do so’). In practice, in a rigid attitude, the ‘asserted preference’ component is rarely articulated and therefore is held to be implicit. Thus, rigid attitudes are most often only shown with the ‘asserted demand’ component made explicit (e.g., ‘I must do well in my forthcoming test’). I will show both cases below.

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Table 1.4  Four Types of Rigid and Extreme Attitudes

In short, we have: Demand = ‘Asserted demand’ component Demand = ▪▪ ‘Asserted preference’ component + ▪▪ ‘Asserted demand’ component

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This rigid attitude is unhealthy for the following reasons: ▪▪ It is rigid in that your client does not allow for the fact that they might not do well. ▪▪ It is inconsistent with reality in that if there was a law of the universe that decreed that your client must do well in their forthcoming test, then there could be no possibility that they would not perform well in it. Obviously, no such law exists. ▪▪ It is illogical in that there is no logical connection between their ‘asserted preference’ component, which is not rigid, and their ‘asserted demand’ component, which is rigid. In logic, something rigid cannot logically follow from something that is not rigid. ▪▪ It will lead to immediate dysfunctional emotions, behaviours and thoughts and interfere with them pursuing their longer-­term goals. It will interfere with them doing well in the sense that the rigid attitude will draw them to focus on how poorly they are doing rather than on what they are doing. A note on language. The rigid attitudes targeted for change in REBT are absolute unconditional musts, as described above. Your clients will often express their rigid attitudes using terms such as ‘must’, ‘should’, ‘got to’, ‘have to’ and so on. As an REBT therapist it is important to be able to distinguish between unconditional rigid attitudes or demands that underpin emotional disturbance and conditional musts and shoulds, which do not. In the course of normal conversation your client is likely to use non-­absolute shoulds regularly. At this point in your training, it is a good idea to familiarise yourself with the different ways of using words like ‘should’ so you can better assess your client’s rigid attitudes. Encouraging your client to place the pertinent descriptor before the word ‘should’ or ‘must’ can help you both to make a clear distinction between absolute and non-­absolute shoulds. Below is a list of different ways of using the word ‘should’. ▪▪ Recommendatory should: This ‘should’ specifies a recommendation for self or other: ‘You should read this book’ translates to ‘I recommend that you read this book,’ or ‘I really should go to bed early tonight’ means ‘It’s in my best interest to go to bed early tonight.’ ▪▪ Predictive should: This use of ‘should’ indicates predictions about the future: ‘I should be on time for my flight’ is interpreted as ‘I predict that I will be on time for my flight.’ ▪▪ Ideal should: This ‘should’ describes ideal conditions. For example, ‘People should not litter’ expresses the viewpoint ‘Ideally, people should not litter.’ Another way of phrasing this ‘should’ is to say ‘In an ideal world x, y and z conditions would exist.’ ▪▪ Empirical should: This ‘should’ points to the existence of reality. It encapsulates the idea that when all conditions are in place for a given event to occur then that event should occur. For example, ‘Because the car is old and in ill repair it should have broken down’ or ‘Because of laws of gravity you should have fallen when you stepped off the ladder.’ ▪▪ Preferential should: This ‘should’ indicates a desire or preference for a given condition to exist: ‘My husband preferably should remember my anniversary,’ for example, carries an implicit additional meaning: ‘It would be good if he remembered but he does not have to.’ ▪▪ Conditional should/must: This ‘should’ denotes that in order for one condition to exist another primary condition must be met. Examples include ‘I should eat healthily in order to become slimmer’ and ‘I must pass the interview in order to be accepted onto the course.’ ▪▪ Absolute should: This term obviously refers to disturbance-­creating rigid attitudes or demands at B in the ABC model of REBT. ‘I absolutely should visit my aunt in hospital’ and ‘I absolutely must tend to my aunt at all times and under any conditions’ are examples of absolute shoulds.

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Awfulising attitudes  When your client holds a rigid attitude towards an adversity (e.g., not getting what they want), then they will tend to conclude that it is awful that they have failed to get what they consider essential. Awfulising, according to REBT theory, can be placed on a continuum from 101% to infinity and means worse than it absolutely should be. Taking your client whose primary rigid attitude is ‘Because I really want to do well in my forthcoming test, therefore I absolutely have to do so,’ their full awfulising attitude is: ‘Not only will it be bad if I fail to do well in my forthcoming test (‘asserted badness’ component), but it would also be awful if I fail (‘asserted awfulising’ component).’ More frequently, this is abbreviated as: ‘It would be awful if I fail to do well in my forthcoming test.’ In practice, in an awfulising attitude, the ‘asserted badness’ component is rarely articulated and therefore is held to be implicit. Thus, awfulising attitudes are most often only shown with the ‘asserted awfulising’ component made explicit (e.g., ‘It would be awful if I do not do well in my forthcoming test’). I will show both cases below. In short, we have:

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Given the fact that the word ‘should’ has many meanings in English, I recommend that you use the qualifier ‘absolute’ when using the disturbance-­creating ‘should’ with your clients. According to Albert Ellis, a rigid attitude is a primary attitude, and three other extreme attitudes are derived from it. These are awfulising attitudes, attitudes of unbearability and self-­, other-­and life-­ devaluation attitudes. I will deal with each in turn.

Awfulising attitude = ‘Asserted awfulising’ component Awfulising attitude = ▪▪ ‘Asserted badness’ component + ▪▪ ‘Asserted awfulising’ component

The awfulising attitude (i.e., ‘It would be awful if I fail to do well in my forthcoming test’) is unhealthy for the following reasons: ▪▪ It is extreme in that your client does not allow for the fact that there are things that can be worse than not doing well in the test. ▪▪ It is inconsistent with reality in that your client really cannot prove that it would be awful if they do not do well. While there is evidence that it would be bad for them not to do well, there is no evidence that it would be more than 100% bad. ▪▪ It is illogical in the sense that the idea that it would be awful if they do not do well (‘asserted awfulising’ component) does not logically follow from the idea that it would be bad if this occurred (‘asserted badness’ component). The former is extreme and does not follow logically from the latter, which is non-­extreme.

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▪▪ It will lead to immediate dysfunctional emotions, behaviours and thoughts and interfere with the person pursuing their longer-­term goals. It will not help them to do well in that it will discourage them from focusing on what they need to do in order to perform well in the test; rather, it will draw them to focus on how poorly they are doing while they are doing it. Attitudes of unbearability  When your client holds a rigid attitude towards an adversity (e.g., not ­ etting what they want), then they will tend to conclude that they can’t bear the adversity. In REBT theory g ‘I can’t bear it’ either means that the person will disintegrate or that they will never experience any happiness again if the adversity occurs. Adhering to an attitude of unbearability discourages your client from bearing the frustration of having their goals blocked and thus they will tend to back away from dealing with these obstacles.

Applying this to my example, when your client holds the rigid attitude ‘Because I really want to do well in my forthcoming test, therefore I absolutely have to do so,’ their attitude of unbearability will be: ‘Because it would be difficult for me to bear not doing well in my forthcoming test (‘asserted struggle’ component) it would be unbearable if I fail (‘asserted unbearability’ component).’ More frequently this is abbreviated as: ‘If I don’t do well in my forthcoming test, it will be intolerable.’

In practice, in an attitude of unbearability, the ‘asserted struggle’ component is rarely articulated and therefore is held to be implicit. Thus, attitudes of unbearability are most often only shown with the ‘asserted unbearability’ component made explicit (e.g., ‘It would be unbearable if I do not do well in my forthcoming test’). I will show both cases below. In short, we have: Attitude of unbearability = ‘Asserted unbearability’ component Attitude of unbearability = ▪▪ ‘Asserted struggle’ component + ▪▪ ‘Asserted unbearability’ component This attitude of unbearability (i.e., ‘If I don’t do well in my forthcoming test, it would be intolerable’) is unhealthy for the following reasons: ▪▪ It is extreme in that your client does not allow for the fact that not doing well is bearable. ▪▪ It is inconsistent with reality in that if there was a law of the universe which stated that your client couldn’t bear not doing well, then they couldn’t bear it no matter what attitude they held. This means that they would literally disintegrate or would never experience any happiness again if they failed to do well in the test. Hardly likely! ▪▪ It is illogical in that the idea that not doing well on a test is unbearable (‘asserted unbearability’ component) does not logically follow from the idea that it is difficult to bear (‘asserted struggle’ component). The former is extreme and does not logically follow from the latter, which is non-­extreme.

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For a detailed discussion of different categories of attitudes of unbearability see Chapter 5 of Neenan and Dryden (1999). Self-­, other-­ and  life-­devaluation attitudes  In this section, I will focus on self-­devaluation attitudes. However, the same substantive points apply to other-­devaluation attitudes and life-­devaluation attitudes. When your client holds a rigid attitude towards an adversity (e.g., not getting what they want) and attributes this failure to themselves, then they will tend to dislike themselves as well as their own poor behaviour. Adopting an attitude of self-­devaluation, for example, will discourage your client from focusing on what they need to do to correct their behaviour.

In my example, if your client who holds the rigid attitude ‘Because I really want to do well in my forthcoming test, therefore I absolutely have to do so’ fails to do well because of their own failings, then their self-­devaluation attitude will be: ‘Because I failed to do well in the test and that is bad (‘negatively evaluated aspect’ component), therefore I am a failure (‘asserted global negative evaluation’ component). Or more frequently: ‘I am a failure for not doing well in the test’ (see below).’

In practice, in a self-­devaluation attitude, the ‘negatively evaluated aspect’ component is rarely articulated and therefore is held to be implicit. Thus, self-­devaluation attitudes are most often only shown with the ‘asserted global negative evaluation’ component made explicit (e.g., ‘I am a failure for not doing well in the test’). I will show both cases below.

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▪▪ It will lead to immediate dysfunctional emotions, behaviours and thoughts and interfere with the person pursuing their longer-­term goals. It will interfere with them doing well in the sense that it will lead them to focus on the ‘unbearable’ aspects of doing poorly rather than on what they need to do to circumvent the obstacles in their way.

In short, we have: Self-­devaluation attitude = ‘Asserted global negative evaluation’ component Self-­devaluation attitude = ▪▪ ‘Negatively evaluated aspect’ component + ▪▪ ‘Asserted global negative evaluation’ component

The self-­devaluation attitude (i.e., ‘I would be a failure if I fail to do well in the forthcoming test’) is unhealthy for the following reasons: ▪▪ It is extreme in that the person only sees themself as a reflection of their behaviour, rather than as a complex person with many different facets. ▪▪ It is inconsistent with reality in that while the person can prove that they did not do well in the test (remember that at this point we have assumed temporarily that their inferred A is true), they cannot 15

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prove that they are a failure. Indeed, if the person was a failure, then they could only ever fail in life. Again, this is hardly likely! ▪▪ It is illogical, in that the person’s conclusion that they are a failure does not logically follow from the observation that they did poorly in the test. They are making a part–whole error of logic. ▪▪ It will lead to immediate dysfunctional emotions, behaviours and thoughts and interfere with the person pursuing their longer-­term goals. It will interfere with them doing well in the sense that the attitude will motivate them to focus on their negatively evaluated self rather than on helping them to deal with their negatively evaluated behaviour. Similar points can be made about other-­and life-­devaluation attitudes.

XX Cs In REBT theory C stands for consequences of holding basic attitudes (at B) towards adversities (at A). These consequences can be emotional, behavioural and thinking in nature. I will deal with each set of consequences in turn. Emotional consequences of attitudes The REBT theory of emotions is distinctive both in the field of psychotherapy and even within the tradition of CBT. It is a qualitative theory of emotions rather than a quantitative theory in that it distinguishes between healthy negative emotions and unhealthy negative emotions. For example, anxiety (unhealthy negative emotion) is deemed to be qualitatively different from concern (healthy negative emotion) rather than quantitatively different. I will discuss this issue more fully in Chapter 4. Healthy negative emotions and unhealthy negative emotions  As I will discuss in detail in Chapter 4, REBT theory holds that your clients experience healthy negative emotions when their preferences are not met, and that they hold a set of flexible and non-­extreme attitudes towards this adversity. While negative emotions (which are listed in Table 1.5) are negative in feeling tone, they are healthy because they encourage your clients to change what can be changed or make a constructive adjustment when the situations that they face cannot be changed. Alternatively, your clients experience unhealthy negative emotions when their preferences are not met, and this time they hold a set of rigid and extreme attitudes towards this adversity. These negative emotions (which are also listed in Table 1.5) are again negative in feeling tone, but they are unhealthy in that they tend to discourage your clients from changing what can be changed and from adjusting constructively when they cannot change the situations that they encounter. In short, healthy negative emotions

Table 1.5  Types of Healthy and Unhealthy Negative Emotions

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Healthy negative emotions

Unhealthy negative emotions

Concern Sadness Remorse Sorrow Disappointment Healthy anger Healthy jealousy Healthy envy

Anxiety Depression Guilt Hurt Shame Unhealthy anger Unhealthy jealousy Unhealthy envy

Mixed emotions  As I will discuss in Chapter 5, when you and your client select a problem to work on, this problem is called a nominated problem. While assessing a nominated problem, you will ask for a concrete example of its occurrence. You need to realise at this point that it is likely that your client will have a mixture of emotions about the situation in which their problem occurred, rather than having a single, unalloyed emotion.

For example, let’s suppose that Betty, your client, has difficulty expressing her negative feelings to her friends when she considers that they take advantage of her. Thus, Betty keeps her feelings to herself with the result that her friends continue to use her. When you come to assess a specific example of this problem you may well find that Betty experiences a mixture of the following emotions: anger, hurt, anxiety and shame. Now, it is important to appreciate that each of these emotions is about a different A, which as you know may be an actual event or, more frequently, an inferred event. Thus, Betty may be: ▪▪ unhealthily angry when focusing on the selfish aspects of her friends’ behaviour ▪▪ hurt when focusing on the uncaring aspects of their behaviour ▪▪ anxious when thinking about the possible rejection that might follow any assertion and ▪▪ ashamed when focusing on her own weakness for not having the courage to speak up.

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stem from flexible and non-­extreme attitudes towards adversities, while unhealthy negative emotions stem from rigid and extreme attitudes towards the same adversities. As I have explained elsewhere (Dryden, 2021a), it is important for you to understand that your clients may use emotion words very differently from the way they are used in REBT theory. As such, you will need to explain very carefully the distinctions between healthy and unhealthy negative emotions and adopt a shared vocabulary when working with your clients. I will discuss this issue fully in Chapter 4.

I argue that if you want to deal with all these issues, then it is helpful to do an ABC assessment for each of the four unhealthy negative emotions that your client experiences. If you try to do one ABC assessment for the entire experience, you will become confused and so, undoubtedly, will your client. In this situation, your client chooses the order in which to deal with these different problematic facets.

Meta-­emotions  As human beings, your clients have the ability to reflect on their experiences and think about their thoughts, feelings and behaviours. Thus, a client’s emotion can itself serve as an A in an ABC episode in which their attitudes determine what subsequent emotions they will have about their prior emotion. These emotions about emotions are referred to as ‘meta-­emotions’ in REBT. As is the case with negative emotions, negative meta-­emotions can be healthy or unhealthy. Thus, as Table 1.6 shows, your clients may have healthy negative meta-­emotions about both healthy and unhealthy negative emotions, and they may also experience unhealthy negative meta-­emotions about both healthy and unhealthy negative emotions. The term used in REBT to describe the latter situation, where clients have emotional problems about their emotional problems, is ‘meta-­emotional problems’. As you will see in Chapter 9, the identification and analysis of meta-­emotional problems plays a particularly important role in the overall REBT assessment process. 17

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Table 1.6  Negative Emotion and Meta-­emotion Matrix Healthy negative emotion

Unhealthy negative emotion

Healthy negative meta-­emotion

Disappointment about being healthily angry

Disappointment about being unhealthily angry

Unhealthy negative meta-­emotion

Shame about being healthily angry

Shame about being unhealthily angry

Behavioural consequences of attitudes REBT theory distinguishes between an overt action and an action tendency. Whenever your client holds an attitude then they have a tendency to act in a certain way. Whether or not your client actualises that tendency and goes on to execute a behaviour consistent with it depends mainly on whether or not they make a conscious decision to go against the tendency. One major task that you have as an REBT therapist is to help your client to see the purpose of going against the action tendencies that are based on rigid and extreme attitudes and to develop alternative behaviours that are consistent with action tendencies based on the corresponding flexible and non-­extreme attitudes. Before you can do this, you need to help your client to identify and examine their rigid and extreme attitudes and to develop and strengthen their alternative flexible and non-­extreme attitudes. I will discuss more fully in Chapter 4 the action tendencies associated with each of the major healthy and unhealthy negative emotions listed in Table 1.5. For now, I just want to stress that according to REBT theory, constructive behaviours and action tendencies stem from flexible and extreme attitudes towards adversities, and unconstructive behaviours and action tendencies stem from rigid and extreme attitudes towards the same adversities. Thinking consequences of attitudes You will recall that earlier I discussed the differences between actual events and inferred events. I argued that although inferences are cognitions, they are best considered as As that trigger your client’s basic attitudes at B. In this straightforward case, the A triggers the B, as shown in the following formula: A → B However, the attitudes that your client holds can influence the subsequent inferences that they make at C. Remember that C can stand for thinking consequences of attitudes as well as emotional and behavioural consequences of attitudes. In this more complicated case, we can denote this influence by the following formula: B → C Inf Let me illustrate the influence of attitudes on subsequent inferences at C in two ways. The first concerns a series of experiments that I conducted with my colleagues in the late 1980s. In one of these studies (Dryden et al., 1989), we asked one group of subjects to imagine that they held a flexible/non-­ extreme attitude towards giving a class presentation and another group to imagine that they held a rigid/ extreme attitude towards the same presentation. Then we asked them to make several judgements

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The second illustration of the effect of attitudes on subsequent inferences at C is a clinical one. Sarah, a 34-­year-­old woman, came into therapy because she was depressed about her facial appearance. At the beginning of therapy, she held the following rigid and extreme attitude: ‘I must be more attractive than I am, and I am worthless because I am less attractive than I must be.’

At this point she thought that everybody that she met would consider her ugly and that no man would want to go out with her. You will note that these latter statements are her inferences about the reactions of people in general and men in particular and that these inferences are the thinking consequences of her rigid and extreme attitudes. During therapy I (WD) worked predominantly at the attitude level and at no time did I encourage her to examine her distorted inferences. As a result of my interventions, Sarah came to hold the following flexible and non-­extreme attitude: ‘I would like to be more attractive than I am, but there is no reason why I must be. I don’t like the fact that I am less attractive than I would like to be, but I can accept myself as a fallible, complex human being with this lack. I am not worthless, and my looks are just one part of me, not the total whole.’

As a result of this attitude change, Sarah reduced markedly her inferences that others would consider her ugly and that men would not want to go out with her. In fact, soon after her therapy ended, she started dating a man whom she later married. This clinical vignette shows quite clearly, I believe, the influence of attitudes on inferences.

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on a series of inferential measures related to giving the presentation, while maintaining the attitude that they were asked to hold. We found that the type of attitudes subjects held had a profound influence on the inferences that they subsequently made. In general, subjects holding the rigid/extreme attitude made more negatively distorted inferences about their performance in the class presentation and about other people’s reactions to it than did subjects who held the flexible/non-­extreme attitude.

XX ABCs interact in complex ways: the principle of psychological interactionism So far in this chapter, I have discussed the ABCs of REBT as if they were separate processes, distinct from one another. During therapy it is important to deal with the ABCs as if they were separate components, because otherwise your clients will end up confused. In reality, though, REBT theory has, right from the outset, advocated the principle of psychological interactionism. This principle states that the events that we choose to focus on, our interpretations and inferences, the attitudes that we hold and the emotions, behaviours and thoughts that stem from these attitudes are all interrelated and reciprocally influence one another, often in complex ways. It is beyond the scope of this book for me to discuss fully and in detail these complex interactions. Those of you who are interested to learn more about the principle of psychological interactionism should consult Ellis (1994) and Dryden (2000).

XX Summary Table 1.7 provides a summary of the main points of this chapter. Having introduced you to the theoretical fundamentals of REBT in this chapter, in the next we will cover what you need to know about the practice of REBT to begin to practise it in a training seminar setting. 19

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Table 1.7  Flexible/Non-­extreme Attitudes vs Rigid/Extreme Attitudes: Examples with Shared and Differentiating Components Attitude

Shared component

I want to do well, but I don’t have to do so Flexible attitude

Differentiating components . . . but I don’t have to do so (‘Negated demand’ component)

I want to do well. . . (‘Desire’ component) I want to do well and therefore I have to do so Rigid attitude

. . . and therefore I have to do so (‘Demand’ component)

It’s bad if I don’t do well, but it’s not terrible Non-­awfulising attitude

. . . but it’s not terrible (‘Non-­awfulising’ component) It’s bad if I don’t do well. . . (‘Evaluation of badness’ component)

It’s bad if I don’t do well and therefore it’s terrible Awfulising attitude

. . . and therefore it’s terrible (‘Awfulising’ component)

It’s a struggle for me to bear the discomfort of not doing well, but I can bear it, it’s worth it for me to do so and I am worth doing it for. I am willing to do so, and I am going to do so -­> doing so Attitude of bearability

. . . but I can bear it (‘I can bear it’ component) . . . it’s worth it for me to do so (‘Worth bearing’ component) . . . I am worth doing it for (‘I’m worth bearing it for’ component) . . . I am willing to do so (‘Willingness to bear it’ component) . . . and I am going to do so (‘Commitment to bear it’ component) -­> behavioural action It’s a struggle for me to tolerate the discomfort of not doing well. . . (‘Struggle’ component)

It’s a struggle for me to tolerate the discomfort of not doing well and therefore I can’t tolerate it Attitude of unbearability

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. . . and therefore I can’t tolerate it (‘Unbearability’ component)

If I fail to do well, that is bad. . . (‘Negatively evaluated aspect’ component) If I fail to do well, that is bad and I’m a failure Devaluation attitude

. . . I am a complex, fallible human being who has failed (‘Asserted complex fallible’ component) . . . and I’m a failure (‘Asserted global negative evaluation’ component)

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. . . but I am not a failure (‘Negated global negative evaluation’ component)

If I fail to do well, that is bad, but I am not a failure, I am a complex, fallible human being who has failed Unconditional acceptance attitude

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What you need to know about the practice of REBT to get started In this chapter, I will outline aspects of the practice of REBT that you need to know before beginning to practise it. In particular, I will discuss (a) the REBT perspective on the so-­called ‘core conditions’, (b) the active-directive therapeutic style adopted by REBT therapists and the skills involved in the implementation of this style, (c) the goals of REBT and (d) the tasks that both therapist and client need to accomplish in the REBT therapy process. The purpose of this chapter is to provide you with an overview of the practice of REBT so that you can make sense of the skills-­based chapters that follow.

XX The ‘core conditions’ In the late 1950s Carl Rogers (1957) wrote a highly influential paper on what have come to be known as the ‘core conditions’. These represent the qualities which therapists need to communicate to clients, who in turn need to experience their presence for their therapeutic effect to be realised. Before I present the REBT perspective on these ‘core conditions’, I want to address one point that Rogers made with which REBT therapists fundamentally disagree. Rogers argued that the ‘core conditions’ that he posited were necessary and sufficient for therapeutic change to occur. In contrast, REBT theory claims that certain therapist qualities are desirable conditions for therapeutic change to occur, but that these qualities are neither necessary nor sufficient conditions for the occurrence of client change (Ellis, 1959). REBT holds the view that therapeutic change can take place in the absence of such therapist qualities, although such change is more likely to occur when these ‘core conditions’ are present. What are the ‘core conditions’ in REBT?

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◀  CHAPTER T W O  ▶

Empathy REBT therapists agree with our person-­centred colleagues in regarding empathy as an important therapist quality. However, we distinguish between two different types of empathy. First, there is affective empathy, whereby you communicate to your clients that you understand how they feel. Here, you need to clarify for yourself and for your clients whether they have experienced healthy or unhealthy negative emotions (see Chapters  1 and  4). This is an important precondition for the second type of empathy delineated in REBT – that is, philosophic empathy. In this type of empathy, you communicate to your clients that you understand the flexible/non-­extreme or rigid/extreme attitudes that underpin their emotional experience. When you are accurate in communicating such philosophic empathy, your clients will often exclaim that they truly ‘feel’ understood. Fundamentals of Rational Emotive Behaviour Therapy: A Training Handbook, Third Edition. Windy Dryden. © 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.

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Unlike our person-­centred colleagues, however, REBT therapists do not see either type of empathy as curative. Rather, we consider that both types of empathy serve to strengthen the therapeutic bond between you and your clients (Dryden, 2011a, 2021b) and that philosophic empathy, in particular, has an educational effect in that it helps your clients to understand the link between their emotions and the attitudes that underpin them. Unconditional acceptance The second ‘core condition’ put forward by Rogers has been variously called ‘unconditional positive regard’, ‘prizing’, ‘non-­possessive warmth’ and ‘respect’. From an REBT perspective these terms are problematic in that they imply that you are giving your clients a global positive evaluation. As such, as an REBT therapist you will prefer to offer your client ‘unconditional acceptance’. This term means that you regard your client as a fallible human being, too complex to merit any kind of global evaluation, who has many different aspects, positive, negative and neutral. In an interview with me (Dryden, 1997a), Ellis cautioned REBT therapists against being overly warm with their clients. He feared that undue therapist warmth would sidetrack the therapeutic process, lead the client to become involved with the therapist at the expense of involving themselves in self-­change methods outside the consulting room, inhibit the therapist from confronting the client and reinforce the client’s need for approval. Interestingly, in a research study (DiGiuseppe et al., 1993), Ellis was rated low on warmth by his clients, a finding consistent with his ideas on the dubious therapeutic value of this variable. Genuineness The third ‘core condition’ advocated by Rogers again has been described differently in the field. It has been called ‘genuineness’, ‘congruence’ and ‘openness’. From an REBT perspective genuineness means that as a therapist you do not hide behind a façade and answer your clients’ questions honestly, even those directed to your personal life, as long as you do not consider that your client will disturb themselves about what you may say. With this caveat, you will, for example, honestly point out to a client why you consider some of their behaviour self-­defeating or anti-­social. In order to do this therapeutically, you need to show the client that you accept them unconditionally and your client needs to experience the presence of your acceptance. Humour Rogers did not write about therapist humour, but I consider this to be a desirable therapist quality in REBT. Ellis has argued that one way of looking at psychological disturbance is that it involves taking oneself, other people and life conditions not just seriously but too seriously (Dryden, 1990). As such, if you can help your client not to take anything too seriously, then this is considered therapeutic in REBT. It is important that you do not poke fun at the client themselves; but, given this, the judicious use of humour through jokes, witticisms and even rational humorous songs (Dryden & Neenan,  2004) can provoke constructive attitude change in those clients who will accept such unorthodox behaviour in therapists.

XX Therapeutic style Although it is possible to practise REBT in a variety of different styles, the style adopted by most REBT therapists and that advocated by Albert Ellis is active-­directive in nature. In my experience as a trainer of REBT therapists, it is this aspect of the therapy with which most trainees struggle. This is especially the

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Therapist directiveness in REBT Let me deal more explicitly with the issue of REBT’s active-­directive therapeutic style. If we break down this style into its constituent parts, we have therapist directiveness and therapist activity. Taking directiveness first, it is important for you to understand the issues towards which you as an REBT therapist will direct your own and, more particularly, your clients’ attention. As REBT is an emotional problem-­ solving approach to psychotherapy, at the outset you will direct your clients to their emotional problems and help them to describe these problems as concretely as possible. Then you will ask clients directly to select a problem that they want to tackle first (I call this the client’s nominated problem), and they are asked, again directly, to provide a specific example of this nominated problem, which is then assessed using the ABC framework discussed in Chapter 1, to be expanded on in Chapters 6–9. During this assessment, you are highly directive. You direct the assessment process because you know what you are looking for, while your clients do not. Your job, at this point, is to encourage your clients to provide you with the kind of information that will enable you to help them. I will deal with the practical skills needed to carry out an effective ABC assessment in Chapters 6–9. For the present, let me outline the direction that such an assessment tends to take. In general, when your client starts to describe a specific example of their target problem, you, as an REBT therapist, should ideally direct their attention to their feelings and help them to identify whether they have experienced a healthy negative emotion or an unhealthy negative emotion. If their negative emotion is unhealthy, then you should1 direct their attention to the A, which, as you will recall, is the aspect of the situation about which they are most disturbed (i.e., the adversity). Once you have identified this, you should direct the discussion to your client’s constructive goals for change.

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case with trainees who have had prior training in person-­centred therapy or psychodynamic therapy. Therapists from these approaches have been schooled in the philosophy that it is therapeutic to give clients as much time and ‘space’ as they need and that the therapist should not interrupt or direct the flow of the client’s exploration or experiencing. In contrast, REBT therapists believe that it is beneficial for you to provide a structure to therapy and to be active in directing your clients’ attention to salient points that will help them to understand their problems more clearly and that will enable them to do something productive to help themselves. Let me make an important point at this juncture: REBT represents one perspective and not the perspective in psychotherapy. It is my practice to explain this to our clients and to mention that there do exist other approaches to psychotherapy that may be equally or more useful to them. I then explain that we will be using the REBT structure for understanding and dealing with their psychological problems and encourage them to experience this to determine whether or not it could be helpful for them. I have found that this approach has been more successful in engaging clients in REBT than a messianic approach which lauds REBT as the only worthwhile approach to therapy and denigrates other therapeutic approaches. Having thus explained to my clients that I will be using a structured approach to therapy, I then get down straight away to demonstrate this approach in action. While REBT is structured, it is important to stress, however, that this therapeutic structure should preferably be used flexibly by you as an REBT therapist. At times, the structure is loose, particularly when you give some of your clients an extended opportunity to talk about their concerns in their own way, while at other times you will employ a tight structure, as when you teach the ABCs of REBT (see Chapter 3).

1   Please note that when I use the word ‘should’ in this context in the book I am using it to denote what I advise you to do. So, it is an advisory ‘should’, not an absolute ‘should’.

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Here, you should explain to your client that given the existence of the adversity, it would be in their best interests to aim for a healthy, albeit negative emotional response to this A. Doing so will, in fact, make it more likely that they will be able to change the adversity if it can be shown to exist or to correct any inferential distortions that they have in viewing it than if they retain an unhealthy negative emotional response to the adversity. Once you have elicited your client’s goals for change, you should direct your attention to an assessment of the rigid and extreme attitudes that underpin your client’s unhealthy negative emotion at C. Once these have been identified, you should direct your client to the attitude–emotion link and ensure that they understand what is known colloquially as the B–C connection. There are, in effect, two B–C connections. The first one helps the client understand the connection between their rigid and extreme attitudes and their disturbed responses to the adversity. This may be called ‘the disturbed B–C connection’. The second one helps the client see the connection between flexible and non-­extreme attitudes and what would constitute healthy responses to the same adversity. This may be called ‘the healthy B–C connection’. This is an important stage in the therapeutic process in that it not only forms a bridge between assessment and intervention but also provides a rationale for the examination of attitudes that follow. As I will show later, while helping your client to examine their attitudes (both rigid/extreme and flexible/non-­extreme), you, as therapist, direct them to three kinds of arguments: empirical, logical and pragmatic. When using empirical arguments, you ask your client to find empirical evidence to support these attitudes; in using logical arguments, you ask your client for logical justification for these attitudes; and in using pragmatic arguments, you ask your client to reflect on the immediate and longer-­term consequences of holding these attitudes. If you are successful at this stage, you will have helped your client to see two things. First, they will understand that their rigid and extreme attitudes are: (a) inconsistent with reality, (b) illogical and (c) unconstructive (in that they lead to dysfunctional emotive, behavioural and cognitive consequences as well as being largely disruptive to their basic goals and purposes). Second, they will understand that their alternative flexible and non-­extreme attitudes are: (a) consistent with reality, (b) logical and (c) constructive (in that they lead to functional emotive, behavioural and cognitive consequences as well as being largely enhancing of their basic goals and purposes). Your client’s insight into the above is likely to be ‘intellectual’ at this point, which means that they may understand the points that you have helped them to see and agree with them, but their strength of conviction in these points will be low; that is, they will not have so-­called ‘emotional’ insight. As such, you will need to help them to see what they need to do to gain emotional insight into their flexible and non-­ extreme attitudes where their conviction in this is high to the extent that it has a productive effect on the person’s emotions, behaviour and subsequent thinking. If you do your job well at this point, your client will see that weakening their conviction in their rigid and extreme attitudes and strengthening their conviction in their flexible and non-­extreme attitudes so that the latter significantly influence how they feel and act takes a lot of what Ellis calls ‘work and practice’. Much of this work is undertaken by your client in the form of homework assignments, which you negotiate with them and which you check in the following session (see Chapters 15 and 16). I hope you can see from this brief overview of doing REBT with a single client problem the extent of therapist directiveness in this approach to psychotherapy. Effective REBT therapists not only vary the amount of structure in therapy sessions but are also flexible concerning how much direction to provide at any point in the therapeutic process (see Dryden & Neenan, 2021 for a fuller discussion of this latter point). Therapist activity We have considered the directive constituent of your active-­directive style as an REBT therapist, but what comprises the active component of this style of doing therapy?

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▪▪ Could it be that you were feeling hurt when your partner ignored you and thus in your eyes showed that he did not care about you? (hypothesis about a feeling based on a disclosure of an inferred A). ▪▪ When you were feeling hurt when your partner, in your view, demonstrated that he did not care that much about you, I wonder if your attitude towards this was something like: ‘He must care about me. If he does not, it proves that I’m not worth caring about’ (hypothesis about a rigid and extreme attitude based on the adversity and a feeling). When advancing such hypotheses, it is very important for you to do two things. First, make it clear to your client that you are testing a hunch (i.e., hypothesis) and that you could be wrong. Emphasise to your client that it is very helpful for them to give you honest feedback about your hunch and that they can help you in the assessment process by correcting or refining your hunches. In this way your client becomes an active participant in the assessment process and not a passive recipient of your clinical wisdom (or otherwise!). Second, pay particular attention to the way in which your client responds to your hypothesis. There is a world of difference between a client saying to you: ‘That’s exactly right. How did you know?’ and ‘Well, er. . . I guess. . . I suppose you could be right.’ In the latter case, it is advisable for you to say something like: ‘You seem quite hesitant. That tells me that my hunch is off target. Can you help me to correct it?’

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Advancing hypotheses  As Ray DiGiuseppe (1991a) has shown, REBT therapists follow the hypothetical-­deductive approach to knowledge, and this is especially true when assessing clients’ problems. This involves using a body of knowledge to form hypotheses about, among other things, (a) what your client may be feeling, based on the inferences they make about the world, and (b) what their attitudes may be, based on these inferences and the feelings they have about these inferred As. Rather than collect a great deal of information before advancing these hypotheses, I recommend that you apply your knowledge of REBT theory to the discrete information provided by your client. Thus, if your client tells you about their feeling, then you can generate a hypothesis about their inferred A, and if they tell you about their feeling and the adversity at A, then you can generate a hypothesis about their attitudes. You should use hypothesis testing particularly when your clients do not respond to open-­ended enquiry regarding the information you are seeking. Here are some examples of theory-­driven questions when testing your hypotheses:

Asking questions  Many people who are trained in person-­centred therapy and other so-­called non-­ directive approaches to therapy and then seek training in REBT are shocked to discover the extent to which REBT therapists employ questions. While they were initially trained to use questions sparingly, if at all, they are now asked to make liberal use of questions. What are your purposes in asking questions as an REBT therapist? In addition to the questions that are a central part of hypothesis testing discussed above, you ask questions for the following reasons. First, you should ask questions to gather general information about the client and their life situation. Second, you should ask questions to obtain specific information in the assessment phase of therapy. These questions are directed towards the salient aspect of the ABC framework that you are currently assessing (see Chapters 6–9). Third, you should ask questions as part of the attitude-­examination phase of therapy – that is, to help you to encourage your client to stand back and examine their attitudes. As I will discuss in greater detail later in the book, I recommend that you ask questions that are directed towards the empirical status, the logical status and the pragmatic status of both your clients’ rigid and extreme attitudes and their alternative flexible and non-­extreme attitudes.

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Fourth, I recommend that you ask Socratic questions to encourage client understanding of healthy REBT principles. While educating his pupils, Socrates would ask them questions to involve them actively in the educational process. Rather than tell them the answers, Socrates asked questions to encourage them to think for themselves as he gently guided them towards the answers. Thus, whenever you can, use the same type of orienting questions. For example, if you want your client to understand why self-­ rating is a pernicious concept, rather than tell them why this is so, ask questions designed to encourage them to think actively about this issue. In response to their incorrect answers, you should ask further questions based on their replies to guide them towards the correct answer. In reality, you will find that you will use a combination of Socratic questioning and brief didactic explanations (see below) to get your teaching points across, because few of your clients will readily respond to the sole use of Socratic questioning. Finally, I recommend that you ask questions to ensure that your client has understood any teaching points that you have made using didactic explanations (see below). REBT can be viewed as an educational approach to therapy. As such, its impact lies not in the information imparted but in the information received and digested. Given this fact, it is important that you gauge whether or not your client comprehends and agrees with the point you are making. First, ask your client to put into their own words their understanding of the point that you have made. Once you are satisfied that your client has understood the point in question, ask your client for their views on that point. You should note two things about the use of questions in REBT. First, avoid asking too many questions, particularly when these are directed at the same target. For example, when seeking information about your client’s rigid and extreme attitudes, ask one question at a time. Second, when you ask a question that is directed at a particular target – for example, the client’s feelings – monitor closely the client’s response to determine whether or not they have answered the question satisfactorily. If not and the information is important, then ask the question again, using a different form of words if necessary. Providing didactic explanations  The second major class of therapist activity involves the use of didactic explanations. As I have already mentioned, REBT can be viewed as an educational approach to therapy. As such, one way of presenting educational points is for you to provide explanations of these points in a didactic manner. You can generally make didactic explanations when your client has not understood a teaching point that you have tried to convey by the use of Socratic questioning (see above). Such explanations involve the deliberate imparting of information concerning, for example: 1. The ABCs of REBT. 2. How REBT theory may help your client to understand their problems. 3. What is likely to happen in REBT. 4. How you construe your role (as therapist) in the therapeutic process and what tasks you need to carry out during therapy. 5. How you construe your client’s role in the therapeutic process and what tasks they need to carry out during therapy. 6. The importance of homework. This illustrative list shows the range of issues that you need to be prepared to explain to your clients. A full list would be much longer. Given this range of issues, it is important for you to have a lot of information at your fingertips and be able to explain a lot of concepts in ways that are meaningful to different clients. I will briefly consider the variety of teaching methods you should be ready to employ as an REBT

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1. It is important for you to explain relevant information clearly and succinctly. Avoid long-­winded, rambling expositions. 2. Explain only one concept at a time. 3. As discussed in the section on questioning, check out your client’s grasp of the point you are making by encouraging them to put their understanding into their own words. This is a particularly important point. It is all too easy for you to think that your client has understood REBT principles because they indicate understanding non-­verbally. This is no substitute for your client putting their understanding into their own words. You should encourage them to do this whenever possible. 4. Elicit your client’s view on the material you have presented, correct any misconceptions they may have and engage them in a dialogue on any matters arising. Using other methods in teaching REBT principles  In addition to Socratic questioning and didactic explanations, you can employ a variety of other active methods to teach your clients REBT principles. As my goal here is to give you a ‘feel’ of the active constituent of the active-­directive therapeutic style, I will briefly mention some of these methods rather than give you a comprehensive list. ▪▪ Use of visual aids. Here you can use posters and flipcharts to present REBT principles in visual form. ▪▪ Self-­disclosure. Here you tell your client how you have used REBT to overcome your emotional problems. You can tailor such self-­disclosure to highlight different REBT principles with different clients. ▪▪ Hypothetical teaching examples. Here you can use hypothetical examples to teach your clients salient aspects of REBT. The ‘money model’ example of teaching the ABCs of REBT presented in Chapter 3 is a good illustration of this. ▪▪ Stories, aphorisms and metaphors. You can employ these methods to teach an REBT principle when you think that your client needs a vivid and memorable illustration of the principle.

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therapist in the next section. Before I do so, let me discuss a number of points that you need to bear in mind while using didactic explanations.

▪▪ Flamboyant therapist actions. These are active examples of the use of humour in REBT. For instance, you may bark like a dog to demonstrate the point that you are not a fool even though you act foolishly at times.

XX The goals of REBT In the late 1960s, Alvin Mahrer (1967) edited a book entitled The Goals of Psychotherapy. In his summary chapter, Mahrer reviewed the ideas of his contributors and argued that the goals of psychotherapy can fall into one of two major categories: (a) relief of psychological problems and (b) promotion of psychological health. REBT therapists would basically concur with this view and extend it. First, you need to help your clients over their psychological disturbances; then you need to help them to address their life dissatisfactions; finally, you can help them to become more psychologically healthy and strive towards self-­actualisation. This is fine as an ideal, but the actual world of the consulting room can be very different. As such, as we will show you, as an REBT therapist you often have to make compromises with your preferred goals (Dryden, 2021a).

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Attitude change Ideally, as an REBT therapist, your preferred goal is to help your clients to achieve attitude change, which means that they relinquish their rigid and extreme attitudes and adopt flexible and non-­extreme attitudes. Your clients may achieve attitude change in specific situations, in one or more broad areas of their lives or more generally. According to REBT theory, the more your clients acquire and implement a general flexible and non-­extreme philosophy, the more psychologically healthy they are deemed to be. From my experience, I make the following predictions: ▪▪ Only a minority of your clients will achieve general change in adopting a flexible and non-­extreme philosophy across the board. ▪▪ A larger number of them will achieve attitude change in one or more broad areas of life. ▪▪ Most of your clients who achieve attitude change will do so in specific situations. When your clients do achieve an attitude change, their inferences tend to be accurate representations of reality and they tend to behave constructively. The point I want to make here is that if your client achieves an attitude philosophic change, this does not mean that they will only change their attitudes. Rather, making an attitude change helps them to make other constructive changes in the ABC framework. Please note that not all of your clients will be willing or able to change their rigid and extreme attitudes, and when this is the case then you need to make compromises with your preferred goals and help your clients in other ways. There are three kinds of change other than attitude change that you can try to bring about. I will now discuss each in turn. Inferential change If you cannot help your clients to achieve attitude change, you can attempt to help them to achieve inferential change. An example of a therapist helping a client to effect inferential change without accompanying attitude change occurred when a colleague of mine failed to help his client develop flexible and non-­extreme attitudes towards her husband’s presumed uncaring behaviour, but succeeded in helping her to correct her faulty inference that he did not care for her. As such, if your client makes an inferential change they will identify and correct distorted inferences and will view situations more accurately. As with attitude change, your clients may achieve inferential change in specific situations, in one or more broad areas of life or more generally. Given the REBT view that inferential distortions stem largely from underlying rigid and extreme attitudes, inferential change is deemed to be unstable, as your clients are more likely to form distorted inferences about themselves, other people and the world if their rigid and extreme attitudes remain unchecked than if they hold flexible and non- ­extreme attitudes. Behavioural change Sometimes when you fail to help your client achieve an attitude change, you can assist them by encouraging them to change their behaviour. Thus, if your client is anxious about being rejected by women, you may help them to minimise rejection by teaching them to improve their social skills. If successful, this may be very therapeutic for your client. However, even sophisticated social skills do not guarantee that your client will never be rejected and thus they remain vulnerable to anxiety in this area because their underlying rigid and extreme attitudes remain.

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Sometimes, if some of your clients are unable or unwilling to hold flexible and non-extreme attitudes towards adversities, you can help them by encouraging them to change their inferences about these events, their behaviour in the hope of modifying these events or you can best help them by encouraging them to leave the relevant situation. In REBT, this is known as changing the A. However, we have extended this to include changing actual As and the situations in which they occur. While such environmental change is fine in the overall context of other psychological changes that your clients may make (especially attitude change), on its own it leaves your clients particularly vulnerable. Because they have not effected any attitude change, such clients take their tendency to disturb themselves from situation to situation. Also, if solely relied upon, opting for environmental change teaches your clients that the only way that they can help themselves is by changing or leaving aversive situations. They will therefore not be motivated to attempt other, more psychologically based changes. Different types of change within a case It is important to stress that a given client may make different types of change on different issues. In the following example please note the point that we have previously made: namely, when a client makes an attitude change they will also make other relevant kinds of change. However, when that client makes an inferential, behavioural or environmental change, they do not often change their rigid and extreme attitudes.

For example, one of my clients, Belinda, came to therapy with the following problems: approval anxiety, coping with pressure from her mother, dealing with her boyfriend’s lateness and a fear of spiders. At the end of therapy Belinda had made an attitude change on the broad issue of approval anxiety, an attitude change on the specific problem of dealing with her mother’s pressure, an inferential change on the specific problem of her boyfriend’s lack of punctuality and an environmental change of A on the specific issue of spiders (i.e., she moved house).

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Changing actual As and situations

Clients’ goals for change So far, I have dealt with the goals that you have for your clients as an REBT therapist. I made the point that while you have preferred goals for client change which you are explicit about, you need to be flexible and be prepared to compromise and accept less preferred goals when it becomes clear that it is very unlikely that your client will achieve attitude change. It is also crucial to note that your clients come to therapy with ideas about what they want to achieve from the therapeutic process. They may state these goals explicitly or these may be implicit in what they say. Sometimes your client’s true goals may be contrary to their stated goals and can only be inferred from their behaviour later in therapy. The point I want to stress here is that your clients’ goals may well be at variance with your goals as an REBT therapist and this may be a source of conflict in the therapeutic process. One way to minimise such conflict is for you to encourage your client to make a problem list (which is updated throughout therapy) and to set goals for each problem. I will discuss this issue later in this book. For now, I want to reiterate that you can be most helpful to your clients by encouraging them to set goals which are based on attitude change. However, as noted above, this is not always possible.

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XX Tasks in REBT When I write of therapeutic tasks I mean specific or general activity that a person carries out in psychotherapy. As Bordin (1979) noted in a seminal paper on the therapeutic alliance, both therapists and clients have tasks to accomplish in therapy. Some of these tasks are common across therapies, while others are specific to a given approach. In this and the following section, I will focus mainly on the tasks that are characteristic of REBT, but in doing so I will consider tasks that are also general in nature. As such, I will not consider specific techniques here, because I want to give an overall picture of task-­related activity in REBT. Your tasks as an REBT therapist In this section, I will mainly concentrate on those of your tasks that are characteristic of REBT; and in the following section, I will consider your client’s tasks in this approach to therapy. Table 2.1 summarises your major tasks as an REBT therapist across the therapeutic process. The beginning phase  Your initial task as an REBT therapist is to establish a therapeutic alliance with your client. At this stage, this primarily involves you: ▪▪ encouraging your client to talk about their concerns; ▪▪ communicating affective empathy; Table 2.1  Your Tasks as an REBT Therapist The beginning phase ▪▪

Establish a therapeutic alliance

▪▪

Socialise your client into REBT

▪▪

Begin to assess and intervene on the nominated problem

▪▪

Teach the ABCs of REBT

▪▪

Deal with your client’s doubts

The middle phase ▪▪

Follow through on the nominated problem

▪▪

Encourage your client to engage in relevant tasks

▪▪

Work on your client’s other problems

▪▪

Identify, examine and help change your client’s core rigid and extreme attitudes

▪▪

Deal with obstacles to change

▪▪

Encourage your client to maintain and enhance gains

▪▪

Undertake relapse prevention and deal with vulnerability factors

▪▪

Encourage your client to become their own therapist

The end phase

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▪▪

Decide on when and how to end

▪▪

Encourage your client to summarise what has been learnt

▪▪

Attribute improvement to your client’s efforts

▪▪

Deal with obstacles to ending

▪▪

Agree on criteria for follow-­ups and for resuming therapy

▪▪ outlining REBT and how it may apply to the problems on this list. Once your client has indicated that REBT could be useful to them, then you can begin to outline what your tasks are in therapy and what you expect of your client. While you need to stress to your client that they need to be active in the therapeutic process, you should do this without presenting an overwhelming picture of what they need to do. I will presently discuss your client’s tasks in REBT. At this point you encourage your client to choose a problem on which to work (known as a nominated problem as it is nominated by the client), you initiate an ABC assessment of this problem and begin to intervene to help your client to overcome the problem. At a salient point in this assessment process, you will endeavour to teach your client the ABCs of REBT. There are several ways of doing this and I will illustrate some of these in Chapter 3. Because REBT has a definite standpoint on people’s problems and its practitioners are prepared to be explicit about this standpoint and the approach to therapy that follows from it, it is likely that your client may have certain doubts or questions about REBT. You should thus be aware of the possible existence of such doubts and questions and be prepared to help your client to express these. Indeed, you should indicate that you welcome questions and the expression of doubts and demonstrate an open, non-­defensive approach to them so that your client can see that their doubts will be taken seriously. Once your client has, for example, expressed a reservation about some aspect of the therapy so far, respond respectfully to this communication, but correct any misconceptions that may underpin their reservation. You should do this with tact and show the client that you accept them as a person even though you are correcting their misconception of REBT. The middle phase  As you and your client get to grips with the latter’s nominated problem, you both begin to move into the middle phase of therapy. It is here that the process of helping clients to examine their attitudes that may have been initiated in the beginning phase takes hold and here that you call upon your client to undertake a number of tasks which are designed to help them (a) to develop their own attitude-­examining skills and (b) to go from an intellectual understanding of salient REBT principles to being able to act on them and make a difference to the way they feel. As you and your client make progress on their nominated problem, you help them to apply their learning to other similar problems. In addition, you both do work on the client’s other problems. As you both gain a detailed understanding of the client’s problems and the rigid and extreme attitudes that underpin these problems, you are in a position to identify and work on the client’s core rigid and extreme attitudes. These are usually few in number and account for the existence of the problems on the client’s problem list. As such, they are expressed in general terms (e.g., ‘I must have the love of significant people in my life’). It is in the middle phase of therapy that most of the obstacles to client change occur. While a detailed consideration of such obstacles is beyond the scope of this introductory text, it is important to bear in mind that an investigation of these obstacles is best done when you unconditionally accept yourself and your client as fallible human beings who have tendencies to block the development of therapeutic progress. In brief, obstacles to client change can be attributed to client factors, therapist factors, the interaction between these two sets of factors or environmental factors (see Dryden, 2022, Dryden & Neenan, 2012 and Ellis, 2002 for a more detailed discussion of obstacles to client change and how to deal with them). As your client makes progress, you encourage them to maintain and enhance their gains. At this point, when they are feeling better, your client may be tempted to stop working on themself. However, this would be a mistake because there is a distinction between ‘feeling better’ and

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▪▪ helping your client to develop a problem list; and

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‘getting better’. The former involves a cessation of symptoms, while the latter involves an attitude change either at a specific level or more generally. In order to help your client achieve an attitude change that is robust, you need to encourage them to continue to maintain their therapeutic gains in the first instance and later to extend these gains to other areas of their life that may not have featured in the therapeutic dialogue. As part of the process of maintaining and extending therapeutic progress, you need to raise the issue of relapse prevention. In particular, this involves the identification of vulnerability factors – that is, As which if encountered would trigger the client’s core and other rigid and extreme attitudes. You may not have discussed these adversities with your client in therapy or, if you have, you may have done so only cursorily. Now is the time for you both to do thoroughgoing work on these issues. Throughout the process of REBT, you will be looking for ways of encouraging your client to take responsibility for their self-­change. Realistically, this particularly comes to the fore during the latter stages of therapy. Here, when your client discusses their problems, you encourage them to take the lead in assessing their underlying rigid and extreme attitudes and in coming up with suggestions for how they might examine, challenge and change these attitudes. At this point, you act more as a consultant, prompting your client to use skills that they have been taught previously, but which they may not think of applying to their own problems, hoping perhaps that you will continue to take the lead as you did in the beginning and early to middle phases of therapy. You will show your client that they have the necessary tools to take the major responsibility for ongoing therapeutic change and that this will be their major task in the time that you have left together. It is often at this point that the issue of ending therapy is first raised and discussed. The end phase  Your first task in the end phase of REBT is to agree with your client the best way to end therapy. There are several ways of bringing therapy to a suitable conclusion. The approach that is generally favoured is to increase gradually the time between sessions so that clients can progressively rely on their own resources as they work towards becoming their own therapists. Whenever I carry out an initial assessment session with new clients who have had previous experience of being in therapy, I ask what they have learnt from that experience. I am frequently struck by how little they claim to have learnt. Whether this means that they have, in fact, learnt little or that they cannot articulate their learning is not clear. If the latter, one remedy is for you to encourage your clients to summarise what they have learnt. Being able to articulate what they have learnt makes it more likely that your clients will retain and apply it after therapy has ended. Consequently, encouraging your clients to summarise and keep a written record of what they have learnt from therapy is one of your key tasks as an REBT therapist in the end phase of therapy. As you review your client’s progress and help them to summarise their learning, it is important that you encourage them to attribute their progress to their own efforts. The way I tend to do this is to take some credit for helping my client to understand their problems and for showing them what they can do about them, but to encourage them to take credit for putting this learning into practice in their own life. If your clients attribute their progress mainly to your efforts, thus minimising their own efforts, they will be less likely to work to maintain and enhance their gains than if they take full responsibility for their contribution to their own progress. Although REBT therapists do not strive to form and maintain close relationships with their clients, the latter do tend to perceive their therapists to be empathic, respectful and genuine (DiGiuseppe et al., 1993). As such, your relationship with your client may well be significant for them and its end may well constitute an A for them. Thus, you should elicit your client’s feelings about the end of their therapeutic relationship with you and uncover, examine and help your clients change their rigid and extreme attitudes if their feelings are negative and unhealthy and constitute obstacles to a productive end to therapy.

Review Table 2.1, which outlines your tasks as a therapist in the three phases of REBT treatment. Use your own words to devise your own ‘aide memoire’ that you can use while you are conducting therapy with your client. Having a readily available ‘crib sheet’ of the tasks involved in each phase of treatment can help you to remain structured and focused, particularly at times when you are feeling a little lost in a therapy session. Below is an example of one REBT trainee’s aide memoire. This example is intended to show you how one trainee reworked Table 2.1. Do not unthinkingly duplicate it. It is important that you make your own aide memoire, using the language that best helps you to understand and remember your therapeutic tasks throughout the beginning, middle and end phases of treatment. The Beginning Phase of REBT Treatment ▪▪ Develop a working relationship with the client. ▪▪ Explain the ‘nuts and bolts’ of REBT practice to the client. ▪▪ Start assessing and tackling the client’s nominated problem. ▪▪ Use the ‘money model’ or ‘brief comparison method’ to teach the ABCs of REBT.

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As an REBT therapist, we advise you not to take a rigid stance to the ending of therapy. Be prepared to resume therapy with your client should the latter be in need of further therapeutic assistance. My practice is to encourage my clients to use their REBT self-­help skills when they encounter the recurrence of old problems or the appearance of new problems. I encourage them to deal with such problems even though they may have to struggle to do so, but tell them to contact me for booster sessions if their struggles fail. What I want to avoid is clients contacting me for extra sessions as soon as they encounter problems before even attempting to use their self-­help skills to overcome these problems. What I advocate, then, is that you set agreed criteria with your clients concerning the resumption of therapy. It is also important that you and your client agree on the timing and purpose of relevant follow-­up sessions.

▪▪ Ask the client if they have any doubts or questions thus far and work to resolve these issues. The Middle Phase of REBT Treatment ▪▪ Continue tackling the nominated problem via helping the client examine both their rigid/ extreme attitudes and their alternative flexible/non-­extreme attitudes. ▪▪ Collaboratively devise homework tasks to help strengthen the client’s flexible and non-­extreme attitudes. ▪▪ Help the client to apply their REBT learning to other problems. ▪▪ Collaboratively examine core rigid/extreme attitudes and core flexible/non-­extreme attitudes. ▪▪ Work through any obstacles to continued therapeutic progress. ▪▪ Urge the client to continue working on positive changes made thus far. ▪▪ Collaboratively devise a relapse prevention plan. ▪▪ Let the client do the bulk of the work in session so they learn to be their own therapist.

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The End Phase of REBT Treatment ▪▪ Agree with the client when and how to terminate therapy. ▪▪ Encourage the client to ‘recap’ what they have learned through therapy. ▪▪ Give the client the credit for their improvement. ▪▪ Discuss any fears about or blocks to ending treatment. ▪▪ Discuss ‘top-­up’ sessions and in what instances to consider resuming therapy.

Your client’s tasks As Bordin (1979) has pointed out, clients have tasks to carry out in psychotherapy. Shortly, I will discuss the specific tasks that your clients are called upon to implement in REBT, but first I will say a few general words about tasks from the client’s point of view. You need to help your clients in several ways in this respect. 1. Help your clients understand the tasks they are called upon to carry out in REBT. If they do not understand what these tasks are, they can hardly be expected to execute them. 2. Help your clients see the relevance of carrying out their tasks and, in particular, the link between these tasks and their goals for change. If your clients do not understand the goal-­directed nature of their tasks, they may well be reluctant to carry them out. 3. Help your clients understand the tasks you as their REBT therapist will be carrying out and help them see the relationship between the execution of your tasks and their goals. Again, unless your clients see this task–goal connection, they may well be puzzled and uncomfortable about your behaviour as an REBT therapist. 4. Help your clients to understand the relationship between their tasks and your tasks as REBT therapist. Therapy is more likely to go smoothly when your clients see that their tasks complement those that you are carrying out than when they lack such understanding. Table 2.2 reviews the client tasks that we will consider in this chapter. Table 2.2  The Client’s Tasks in REBT ▪▪

Specify problems

▪▪

Be open to the therapist’s REBT framework

▪▪

Apply the specific principle of emotional responsibility

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Apply the principle of therapeutic responsibility

▪▪

Disclose doubts, difficulties and blocks to change

Specify problems  The first client task that I will discuss concerns ability and preparedness to be specific about problems. REBT is a problem-­solving approach to psychotherapy and as such you will need to ask your client to focus on their problems and discuss them in a specific manner, giving typical, explicit examples of these problems to enable you to carry out a proper ABC assessment. If your client cannot be specific about their problems, they will probably derive less benefit from REBT than if they can talk specifically about their concerns. In addition, if your client is not specific about their problems you will have greater difficulty in carrying out your tasks than if they are specific about them. These tasks are themselves specific in nature, and if you are to perform them effectively, you need specific information from your client.

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Apply the specif ic principle of emotional responsibility  The third client task that I wish to address involves your client applying the specific principle of emotional responsibility. I distinguish between the general and specific principles of emotional responsibility and discuss this further later in this text. The specific principle of emotional responsibility states that your client largely makes themself disturbed by the rigid and extreme attitudes that they hold towards life’s adversities. When your client applies this principle, they actively look for these rigid and extreme attitudes whenever they experience an unhealthy negative emotion, and they counter any tendency that they may have to blame other people and situations for causing their emotions. While this principle places the responsibility for their psychological problems fairly and squarely on your client, it does not preclude them from acknowledging that adversities contribute to their problems. It is important to note that responsibility is a different concept from blame and as such the specific principle of emotional responsibility does not advocate your client blaming themselves for making themselves disturbed.

W h a t y o u n e e d t o k n o w a b o u t t h e   p r a c t i c e o f REBT t o g e t s t a r t e d

Be open to the REBT framework  The second client task that I will discuss involves their willingness to listen to your explanations of their problems and to be open-­minded about the REBT viewpoint on the nature of their problems, how they perpetuate these problems and what they need to do to overcome these problems. If your client’s view of their problems is markedly at variance with the REBT perspective, and they are not willing to entertain an alternative perspective, then therapy will quickly stall. Now, I am not suggesting that your client should accept uncritically the REBT perspective on their problems. Indeed, Ellis (2002) has argued that suggestibility and gullibility are hallmarks of emotional disturbance. I am saying, however, that your client needs to be open-­minded enough to consider the merit of your ideas and to be sceptical (in the healthy sense) about these ideas. You can help your client to think for themselves about these matters by encouraging them to express their doubts, reservations and objections to REBT principles so that you can have an open dialogue on these ideas where you correct your client’s misconceptions in a respectful manner. If you are rigid about REBT theory, you not only serve as a poor role model of flexibility, you are also likely to create a situation where a polarisation of viewpoints occurs, with the result that your client defends their rigid/extreme position and cannot thereby benefit from therapy.

Apply the principle of therapeutic responsibility  The fourth client task that I will consider involves your client applying the principle of therapeutic responsibility. This principle logically follows on from the specific principle of emotional responsibility. It involves your client acknowledging that in order to overcome their emotional problems they need to put into practice the REBT theory of therapeutic change (in this case, attitude change), which I discuss more fully in the latter half of this book. Albert Ellis and I summarised this in the second edition of our book The Practice of Rational Emotive Behaviour Therapy (Ellis & Dryden, 1997). We say there that to effect an attitude change your clients are advised to: 1. Realise that they create, to a large degree, their own psychological disturbances, and that while environmental conditions can contribute to their problems, they are in general of secondary consideration in the change process. 2. Fully recognise that they do have the ability to significantly change these disturbances. 3. Understand that emotional and behavioural disturbances stem largely from rigid and extreme attitudes. 4. Detect their rigid and extreme attitudes and discriminate these from their alternative flexible and non-­extreme attitudes.

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5. Examine both their rigid and extreme attitudes and their flexible and non-­extreme attitudes using the logical-­empirical methods of science. 6. Work towards the internalisation of their new flexible and non-­extreme attitudes by employing cognitive, emotive and behavioural methods of change. 7. Continue this process of examining both sets of attitudes and of using multimodal methods of change. Disclose doubts, dif f iculties and  blocks to  change  The final client task that I will consider involves your client disclosing to you their doubts about REBT principles, the difficulties that they experience in implementing REBT and any blocks to psychological change that they encounter. If your client keeps these doubts, difficulties or blocks to themselves or, worse, if they dissimulate by actively stating that they agree with REBT principles, that they are able to implement its techniques without difficulty and that they encounter no blocks to change, then they will derive little benefit from therapy. Now, whether your client discloses their doubts, etc., will depend, in part, upon you providing the kind of therapeutic climate that encourages such disclosure. However, assuming that you succeed in providing this climate and ask your client for this information, then they have the responsibility to provide it.

Practise eliciting and resolving blocks to psychological change, problems implementing REBT and specific doubts about REBT principles through role-­play exercises with a fellow trainee. Agree on a scenario but ensure that your role-­play partner makes it neither too easy nor too difficult for you to elicit or resolve their concerns. In real therapy situations your clients will often find it difficult to articulate their problems, doubts or reservations with REBT principles and application. Encourage your role-­play client to select a specific issue that is blocking their therapeutic progress without disclosing it to you prior to the exercise. Doing this will more accurately replicate real client–therapist interaction and give you a more valuable practice experience. Record your work in this exercise and play it to your REBT trainer for feedback.

I have now presented the basic information about the theory and practice of REBT that you need to know to begin to use this approach to therapy. In the next chapter, I will discuss how to teach clients the ABCs of REBT.

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Teaching the ABCs of REBT As I have stressed so far in this book, the ABC framework is at the heart of the REBT theory of psychological disturbance. It provides both you and your client with a way of assessing the client’s problems. As an accurate assessment of the client’s problems is a prerequisite for effective intervention, the ability to teach the ABCs of REBT clearly and succinctly to clients is an important skill in which all aspiring REBT therapists need to develop competence. There are a number of ways in which you can teach your clients the ABCs, and in this chapter I will demonstrate a few of these methods.

TEACHING THE ABCs OF REBT

◀ CHAPTER THREE  ▶

XX The money model The money model is a fairly elaborate method in which you help your client to see the primary role of rigid attitudes and the secondary role of awfulising attitudes in psychological disturbance and the corresponding roles that flexible attitudes and non-­awfulising attitudes play in promoting a healthy response to life’s adversities. It is a method originally devised by Albert Ellis and employed by him frequently in his clinical work. As such, it is an important method to learn and use when appropriate. Let me go through the money model by providing a typical example of how I demonstrated it with a trainee (in this case, Robin) on a first-­level training course in REBT. In this role-­play, I ask Robin to play the role of a client, while I play the role of REBT therapist.

Windy: OK, Robin. I’d like to teach you a model which explains the factors that account for people’s emotional problems. Now, this is not the only explanation in the field of counselling, but it is the one that I use in my work. Are you interested in learning about this explanation? Robin: Yes, I am. Windy: Good. Now, there are four parts to this model. Here’s part one. I want you to imagine that you have £10 in your pocket and that you hold the following attitude: ‘I would prefer to have a minimum of £11 on me at all times, but it’s not essential that I do so. It would be bad to have less than my preferred £11, but it would not be the end of the world.’ Now, if you had a strong conviction in this attitude, how would you feel about only having £10 when you want but don’t demand a minimum of £11?

Fundamentals of Rational Emotive Behaviour Therapy: A Training Handbook, Third Edition. Windy Dryden. © 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.

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Robin: I’d feel concerned. Windy: Right. Or you’d feel annoyed or disappointed. But you wouldn’t kill yourself. Robin: Certainly not. Windy: Right. Now here’s part two of the model. This time you hold a different attitude, which is: ‘I absolutely must have a minimum of £11 on me at all times. I must! I must! I must! And it would be the end of the world if I had less.’ Now, with this attitude you look in your pocket and again find that you only have £10. Now, how would you feel this time about having £10 when you demand that you must have a minimum of £11? Robin: I’d feel quite panicky. Windy: That’s exactly right. Now, note something really important. Faced with the same situation, different attitudes lead to different feelings. Now the third part of the model. This time you still have the same attitude as you did in the last scenario, namely: ‘I absolutely must have a minimum of £11 on me at all times. I must! I must! I must! And it would be the end of the world if I had less.’ This time, however, in checking the contents of your pocket you discover two pound coins nestling under the £10 note. How would you feel about now having £12 when you believe that you have to have a minimum of £11 at all times? Robin: I’d feel very relieved. Windy: Right. Now here is the fourth and final part of the model. With that same £12 in your pocket and that same attitude, namely: ‘I absolutely must have a minimum of £11 on me at all times. I must! I must! I must! And it would be the end of the world if I had less,’ one thing would occur to you that would lead you to be panicky again. What do you think that might be? Robin: Let me think. . . I believe that I must have a minimum of £11 at all times; I’ve got more than the minimum and yet I’m anxious. Oh, I see. I’m now saying, ‘I must have a minimum of £13.’ Windy: No. You are sticking with the same belief as before, namely: ‘I must have a minimum of £11 on me at all times. I NOW have £12. . .’ Robin: Oh! I see. . . I NOW have the £12. Right, so I’m scared I might lose £2. Windy: Or you might spend £2 or you might get mugged. Right. Now, the point of this model is this. All humans, black or white, rich or poor, male or female, make themselves disturbed when they don’t get what they believe they must get. And they are also vulnerable to making themselves disturbed when they do get what they believe they must get, because they could always lose it. But when humans stick rigorously (but not rigidly) to their preferences and recognise that they don’t have to have their preferences met then they will feel healthily concerned when they don’t have what they prefer and will be able to take constructive action under these conditions to attempt to prevent something undesirable happening in the future. Now, in our work together we will pay close attention to the differences between rigid attitudes and flexible attitudes. Is that clear? Robin: Yes. Windy: Well, I’m not sure I’ve made my point clearly enough. Can you put it into your own words?

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Step 1. Ask the client if they are interested in an explanation of emotional problems. Step 2. Present part one of the model. Stress that the client has less money than they prefer and that  they don’t have to have their desire met (flexible attitude) and provide the associated non-­awfulising attitude. Enquire about their feeling. If they do not give you a healthy negative emotion (HNE), explain why this would be their emotional response. Step 3. Present part two of the model. Stress again that the client has less money than they want, but this time add the rigid component to make their attitude rigid and provide the associated awfulising attitude. Enquire about their feeling.

TEACHING THE ABCs OF REBT

Let me now briefly summarise the steps here. As I do so, go back to the dialogue and see if you can follow the steps.

Step 4. Emphasise that different attitudes towards the same adversity lead to different feelings. Step 5. Present part three of the model. Stress that the client still holds a rigid attitude but this time has more money than they demand. Again provide the associated awfulising attitude. Enquire about their feeling. If they do not give you a plausible response explain why their response is incorrect and prompt until their response is correct. Step 6. Present part four of the model. Stress that the person still has more money than they demand; remind them of the rigid attitude giving once again the associated awfulising attitude. Then ask the person to imagine holding this rigid/extreme attitude and then having a thought that leads them to feel disturbed again. Enquire about the nature of this thought. Encourage them to identify possible thoughts by themselves, but give suggestions if they are stuck. Step 7. Summarise all the information emphasising the importance of distinguishing between flexible/non-­extreme attitudes and rigid/extreme attitudes and showing their differential effects. Correct your client’s errors One of the important points to note when you present the full money model to your clients is that you will have to both correct the errors that they make in responding to your questions and explain the nature of these errors. For example, when you present the first part of the model (i.e., the client is asked to imagine holding a flexible and non-­extreme attitude) your client may say that they would experience an unhealthy negative emotion (UNE) rather than an HNE. Unless you correct this error and explain why it is an error, your client may take away erroneous information. Here is an example of what I mean.

Windy: There are four parts to this model. Here’s part one. I want you to imagine that you have £10 in your pocket and that you hold the following attitude: ‘I would prefer to have a minimum of £11 on me at all times, but it’s not essential that I do so. It would be bad to have less than my preferred £11, but it would not be the end of the world.’ Now, if you had a strong conviction in this attitude, how would you feel about only having £10 when you want but don’t demand a minimum of £11? Sarah: I’d be very anxious.

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Windy: I don’t think you would. Don’t forget that your attitude is that it would be undesirable not having the £11, but that you don’t need it. Also, you don’t believe it would be the end of the world if you did not have the £11, rather that it would be unfortunate not to have this amount. Think carefully about this. Now how do you think you would feel? Sarah: Oh, I see. I’d be concerned.

Common trainee errors in teaching the money model When you present the money model correctly, it is a potent way of teaching the ABC model. However, it is difficult to master and trainees do experience difficulty in learning it. When you first practise the money model, you may make a number of errors. In discussing such following errors, I will use illustrative dialogue from training situations. Failure to  distinguish fully between f lexible and rigid attitude  A very common error  that you may make is not keenly discriminating between a flexible attitude and a rigid attitude. Typically, when this happens you do not make explicit both parts of the flexible attitude, as shown in the ­dialogue below.

Mary (in the role of counsellor): Now, there are four parts to this model. Here’s part one. I want you to imagine that you have £10 in your pocket and that you hold the following attitude: ‘I would prefer to have a minimum of £11 on me at all times.’ Now, if you really believed this, how would you feel about only having £10 when you want a minimum of £11? Windy (as trainer): Well. It was good that you began by stressing that there are four parts to the model, and you started the model correctly with the ‘asserted preference’ component of a flexible attitude. However, it is important that you present the client with the full version of the flexible attitude, which is in two parts. The first part of the flexible attitude involves asserting the person’s preference, which is, as you said correctly: ‘I would prefer to have a minimum of £11 on me at all times.’ However, REBT theory states that people can easily change their preferences to demands, and the major way of guarding against this when teaching the money example is to negate the person’s demand as well as asserting their preference. You do this by saying: ‘I would prefer to have a minimum of £11 on me at all times, but it’s not essential that I do so.’ You will recall that REBT theory states that flexible attitudes are primary attitudes and that three non-­extreme attitudes are derived from these flexible attitudes, namely: non-­awfulising attitudes, attitudes of bearability and unconditional self-­/other-­/life-­acceptance attitudes. To reinforce the flexible attitude here, I recommend that you add the non-­awfulising attitude derivative. When you do this, assert the ‘evaluation of badness’ component and negate the ‘awfulising’ component: ‘It would be bad to have less than my preferred £11, but it would not be the end of the world.’

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XX F  ailure to clarify vague emotional statements, thus not distinguishing between HNEs and UNEs

TEACHING THE ABCs OF REBT

If we put together the primary flexible attitude and its non-­ awfulising attitude derivative, remembering to assert the flexible and non-­extreme components and to negate the rigid and extreme components, we have: ‘I would prefer to have a minimum of £11 on me at all times, but it’s not essential that I do so. It would be bad to have less than my preferred £11, but it would not be the end of the world.’

As an REBT therapist you place great emphasis on encouraging your clients to be clear rather than vague about their emotions. Thus, if your client describes a vague emotion in the money model, you need to help them clarify its precise nature.

Windy: OK, Mary. Why not back up and then continue? Mary: Now there are four parts to this model. Here’s part one. I want you to imagine that you have £10 in your pocket and that you hold the following attitude: ‘I would prefer to have a minimum of £11 on me at all times, but it’s not essential that I do so. It would be bad to have less than my preferred £11, but it would not be the end of the world.’ Now, if you really believed this, how would you feel about only having £10 when you want but don’t demand a minimum of £11? Arthur (in the role of client): Upset. Mary: Right. Now here’s part two of the model. Windy: OK. Let’s stop there. A very important part of REBT theory states that when a person faces a negative A, like having £1 less than their goal, their unhealthy negative emotions about this A stem largely from rigid and extreme attitudes, while their healthy negative emotions stem largely from flexible and non-­extreme attitudes. In order to clearly teach the client the difference between flexible/non-­extreme and rigid/extreme attitudes in the money model, it is very important that you help them to differentiate clearly their healthy negative emotions from their unhealthy negative emotions. One way of doing this is to be precise about emotional terms. Now, when your client used the word ‘upset’ just then, we do not know whether this refers to a healthy negative emotion like concern, disappointment and annoyance or to an unhealthy negative emotion like anxiety, self-­pity or anger. If you accept the word ‘upset’ uncritically here, then you are making life more difficult for yourself later in the model when you come to show the important role that rigid and extreme attitudes have in underpinning disturbed emotions. If by the word ‘upset’ here your client means a disturbed negative emotion, then they will later be confused. They will say something to themselves like: ‘Wait a minute. The therapist is now showing me that rigid and extreme attitudes underpin disturbed negative emotions. But they also accepted my point that my ‘upset’ feelings – which I also see as disturbed – stem from flexible and non-­extreme attitudes. I’m very confused.’

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So instead of accepting the term ‘upset’ uncritically, you need to clarify what your client means by it and proceed accordingly. Let me demonstrate how to do this. In doing so, I want Arthur in the first instance to construe ‘upset’ as a healthy negative emotion and in the second instance as an unhealthy negative emotion and I’ll show you what to do in each case.

Here is how I modelled skilful therapist behaviour for Mary in both instances. Instance 1: When ‘upset’ is an HNE

Windy: So you say that you would feel upset if you have £10 when you want but don’t demand a minimum of £11. I’m not quite sure what you mean by ‘upset’. Do you mean upset in a healthy concerned way, for example, or upset in an unhealthy anxious way? Arthur: Put that way, I’d be concerned rather than anxious.

Instance 2: When ‘upset’ is a UNE

Windy: So you say that you would feel upset if you have £10 when you want but don’t demand a minimum of £11. I’m not quite sure what you mean by ‘upset’. Do you mean upset in a healthy concerned way, for example, or upset in an unhealthy anxious way? Arthur: Put that way, I’d be anxious rather than concerned. Windy: Now, I may be wrong here, but I don’t think you would. Don’t forget you hold that while you would like to have a minimum of £11 at all times, it is not essential. Can you see the difference between the attitude that having £11 at all times is desirable but not essential and the attitude that having £11 at all times is absolutely essential? Arthur: Yes. In the first case, my attitude is that it would be nice to have it but that it is not a necessity, and in the second case, my attitude is that it is essential. Windy: That’s right. Now, which attitude would lead to un-­anxious concern and which to anxious overconcern? Arthur: I see what you mean. I’d feel concerned about not having the £10 if I held the attitude that having the £11 at all times is desirable but not necessary.

XX F  ailure to emphasise the rigid and extreme components of the client’s rigid and extreme attitude in part two When going over part two of the model, it is important to emphasise the rigid and extreme components of your client’s rigid and extreme attitude. If this is not done, your client may not understand its full implications. Let’s go back to Mary and Arthur. 44

Windy: Let’s stop there, Mary. Now, at this point, it’s really important to emphasise the rigid and extreme components of the rigid and extreme attitude you are asking Arthur to hold in his mind. Just mentioning the must with little or no emphasis is usually insufficient. Listen carefully to what I usually say and see if you can see the difference between this and what you said. ‘OK, Arthur, here’s part two of the model. This time you hold a different attitude, namely: ‘I absolutely must have a minimum of £11 on me at all times. I must! I must! I must!1 And it would be the end of the world if I had less.’ Now, with this attitude you look in your pocket and again find that you only have £10. Now, how would you feel this time about having £10 when you demand that you must have a minimum of £11?

TEACHING THE ABCs OF REBT

Mary: Right. Now here’s part two of the model. This time you hold the following different attitude: ‘I must have a minimum of £11 on me at all times.’ With this attitude you look in your pocket and again find that you only have £10. Now, how would you feel this time about having £10?

Mary: Well, first, you used the phrase ‘absolute must’ where I just used the word ‘must’. Second, you repeated the phrase ‘I must’ three times with a considerable degree of emphasis. Then you provided an awfulising attitude [pause]. Windy: Why do you think I did that? Mary: I’m not sure. Windy: I did that to emphasise the extreme component of the rigid/extreme attitude. Mary: I see. Then you asked Arthur how he would feel about having £10 when he demanded that he must have a minimum of £11? So once again you emphasised the rigid attitude where I did not.

XX Failure to summarise accurately all the points One of the most difficult parts of the money model is the summary. To summarise all the points effectively, you need to have a full understanding of these points and the sequence in which they need to be presented. Let’s consider Mary’s summary.

Mary: Now, the point of this model is this. All humans, black or white, rich or poor, male or female, are upset (a) when they don’t get what they demand. And they are also vulnerable to becoming upset (b) when they do get what they demand because they could always lose it. But when people stick with their desires (c) they won’t get upset. Windy: That was a pretty good first attempt, Mary. You were able to show Arthur some key parts of the model such as the difference between rigid attitudes and flexible attitudes. There are three points that you need to consider in order to improve this summary.

  I am using italics here to mirror the emphasis of my voice at this point.

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[The following numbers correspond to the bracketed numbers shown in Mary’s summary.] (i) First, you used the word ‘upset’ throughout. This is problematic for two reasons. First, as ­discussed before, ‘upset’ is a vague word and therefore you are helping the client neither to be ­precise about their own emotions nor to differentiate between healthy and unhealthy negative emotions. Second, in using ‘upset’ throughout the summary, you have unwittingly taught your client that emotional upset stems from both rigid and extreme attitudes and flexible and non-­extreme attitudes. This is obviously going to be confusing for them. So, what could you do differently next time? Mary: I’ll be precise in my use of emotional language and use words that clearly reflect healthy negative emotions like concern and words that clearly reflect unhealthy negative emotions such as anxiety. Windy: Excellent. My second piece of feedback is as follows. (ii) At the end you said, ‘But when people stick with their desires they won’t get upset.’ Compare this with what I generally say at this point: ‘But when humans stick rigorously (but not rigidly) to their preferences and recognise that they don’t have to get these preferences met then they will feel healthily concerned.’ Can you see the difference between these two statements? Mary: Well, I stated only part of the flexible attitude, while you stressed the full flexible attitude belief and that in holding this attitude people won’t implicitly change their desires to rigid demands. Also, you stressed that people can rigorously hold a preference without turning it into a rigid attitude. I didn’t mention that. Finally, while I used the vague term ‘upset’, you were explicit in stressing that a specific healthy negative emotion stems from a flexible/non-­extreme attitude. Windy: Again, that is a full and excellent answer. Now here is my third and final piece of feedback. At the very end you mention, albeit vaguely, that a negative emotional state stems from a flexible/ non-­extreme attitude, whereas I stress that holding a flexible/non-­extreme attitude also leads to people being able to take constructive action to attempt to prevent something undesirable happening in the future. The summary is difficult to master, so let me break it down point by point. ▪▪ Point 1. Rigid/extreme attitudes underpin disturbance when the A is negative. ‘All humans, black or white, rich or poor, male or female, make themselves disturbed when they don’t get what they believe they must get.’ ▪▪ Point 2. Rigid/extreme attitudes leave people vulnerable to disturbance when the A is positive, because the A could become negative in the future. ‘. . . And they are also vulnerable to making themselves disturbed when they do get what they believe they must get, because they could always lose it.’ ▪▪ Point 3. Flexible/non-­extreme attitudes underpin healthy negative emotions and constructive behaviour when the A is negative. ‘. . . But when humans stick rigorously (but not rigidly) to their preferences and recognise that they don’t have to get these preferences met then they will feel healthily concerned when they don’t have what they prefer and will be able to take constructive action under these conditions and to prevent something undesirable happening in the future.’

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In order to master this important method of teaching the ABCs of REBT, let me suggest the following steps. Step 1. Rewrite my version on pp. 39–40, using your own words, ensuring that you don’t change any of the meaning or any of the teaching steps. Step 2. Learn it off by heart, being careful to focus on the meaning of your words. Don’t do this parrot fashion, though. Step 3. Test yourself by putting the model on a digital voice recorder. Play both yourself and a very cooperative client. If you get stuck, consult your written script. Do this until you can teach the model smoothly without self-prompting.

TEACHING THE ABCs OF REBT

XX Summary

Step 4. Pair up with a fellow trainee and teach them the model, ensuring that your colleague plays a cooperative client. Step 5. Repeat step 4, but this time encourage the client to make minor errors of understanding in the client role. Correct these errors until the ‘client’ understands the model fully. Step 6. Repeat step 4, but this time encourage the client to make major errors of understanding in the client role. Again, correct these errors until the ‘client’ understands the model fully. Step 7. Teach the model to several people who are unfamiliar with REBT. Step 8. Bring any problems in teaching the model to your REBT trainer or supervisor.

XX The lateness example While the money model is a comprehensive approach to teaching the ABCs of REBT, not all clients relate to it or understand it. The lateness example is an alternative to the money model. It comprises the same seven steps and four parts as the money model. It is important that you remember to teach your client the learning points in the same order. Below is a script of the lateness example. The wording of the script is altered slightly from that of the money model above. This is done to illustrate how you can put these methods of teaching the ABCs into your own language provided you keep the meaning intact and retain the teaching sequence.

Windy: OK, Paul, I’d like to teach you a model which explains the factors that account for people’s emotional problems. There are other explanations in the field of counselling, but this is the one I use in my work. Are you willing to hear about this explanation? Paul: Yes. Windy: OK. There are four parts to this model. Now here’s part one. I’d like you to imagine that you are 10 minutes late for an appointment and that you hold the following attitude: ‘I prefer to be on time for all my appointments, but it’s not essential that I am on time. It’s bad to be late, but it’s not the end of the world.’ So, if you really had strong conviction in this attitude, how do you imagine you would feel about being 10 minutes late for your appointment bearing in mind that you want but don’t demand that you arrive on time?

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Paul: I guess I’d be concerned. Windy: Right. Or perhaps you’d feel annoyed or disappointed, but the point is you wouldn’t kill yourself over it, right? Paul: No, certainly not. Windy: Now here’s part two of the model. This time you hold a different attitude, namely: ‘I absolutely must, under all conditions, be on time for appointments. I must! must! must! arrive on time and it would be the end of the world if I was late!’ Now, while holding this attitude you look at your watch and realise that you are in fact 10 minutes late. How would you feel about being 10 minutes late when you are demanding that you must always arrive at appointments on time? Paul: I’d feel panicky. Windy: That’s exactly right. Now, I’d like you to take note of a very important point. In the same situation different attitudes lead to different types of feelings. Let’s move on to part three of the model. This time you hold the same attitude as you did in the last scenario: ‘I absolutely must be on time for all my appointments, I must! must! must! It would be the end of the world if I was late!’ This time, though, you glance up at a clock in the street and realise that your watch is 20 minutes fast. So in fact you are actually 10 minutes early for your appointment. How do you imagine you would feel about being 10 minutes early when you hold that you absolutely have to be, absolutely must be on time for your appointment? Paul: Uh. . . I’d be relieved. Windy: That’s right: you would feel relieved. Now consider the fourth and final part of the model. Realising that you’re 10 minutes early for your appointment and still holding the same attitude, namely: ‘I must be on time for all my appointments. I must! must! must! To be late would be the end of the world!’ something will occur to you that will cause you to feel panicky again. Can you think what that might be? Paul: That I’ll be delayed somehow and still end up arriving late. Windy: Precisely. Or that the street clock was wrong or perhaps you got the appointment time wrong and you are in fact late rather than 10 minutes early. Right. Now, the point this model makes is that all humans – be they male or female, rich or poor, of any age or race – make themselves emotionally disturbed when they don’t get what they truly believe they must get. Even when they do get or achieve what they believe they absolutely must, they are still vulnerable to further disturbance in the future. Why? Because it is always possible that they will lose it. But when humans hold flexible attitudes whereby they acknowledge their preferences and recognise that they don’t have to have their preferences met, they experience healthy negative emotions like concern when they don’t get or achieve what they prefer. They are also able to take constructive action when their preferences are not met and are able to work towards preventing something undesirable happening in the future. So in our work together we’re going to focus closely on the differences between rigid attitudes and flexible attitudes. Does that make sense to you? Paul: Yeah, it does. Windy: Good. These are some pretty complex principles I’ve been showing you. Can you tell me what you’ve understood from the model, in your own words, so I can check that I’ve made the points clearly?

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XX Simpler ways of teaching the ABCs Despite your best efforts, some of your clients will not be able to readily digest the information included in the lateness example and the money model. As such, it is useful to have at your fingertips one or two simpler ways of teaching the ABCs. The brief money model

TEACHING THE ABCs OF REBT

Having already addressed correcting client errors and common trainee-­therapist errors with respect to the money model, these points will not be reiterated here.

When taught accurately and clearly, the full money model is a powerful way of teaching the ABCs of REBT. However, you need to shorten it for those of your clients who you think would not be able to understand the full money model. This involves presenting the first two parts of the model (as broken down in steps 1 to 4 on pp. 39–40). These first two parts show that rigid and extreme, awfulising attitudes underpin UNEs, and flexible and non-­extreme, non-­awfulising attitudes underpin HNEs. You can also just present these two parts when you are pressed for time or when you want to present the bare bones of the REBT model. Let us present those two parts again here.

Windy: OK, Robin. I’d like to teach you a model which explains the factors that account for people’s emotional problems. Now, this is not the only explanation in the field of counselling, but it is the one that I use in my work. Are you interested in learning about this explanation? Robin: Yes, I am. Windy: Good. Now, there are two parts to this model. Here’s part one. I want you to imagine that you have £10 in your pocket and that you hold the following attitude: ‘I would prefer to have a minimum of £11 on me at all times, but it’s not essential that I do so. It would be bad to have less than my preferred £11, but it would not be the end of the world.’ Now, if you had a strong conviction in this attitude, how would you feel about only having £10 when you want but don’t demand a minimum of £11? Robin: I’d feel concerned. Windy: Right. Or you’d feel annoyed or disappointed. But you wouldn’t kill yourself. Robin: Certainly not. Windy: Right. Now here’s part two of the model. This time you hold a different attitude, which is: ‘I absolutely must have a minimum of £11 on me at all times. I must! I must! I must! And it would be the end of the world if I had less.’ Now, with this attitude you look in your pocket and again find that you only have £10. Now, how would you feel this time about having £10 when you demand that you must have a minimum of £11? Robin: I’d feel quite panicky. Windy: That’s exactly right. Now, note something really important. Faced with the same situation, different attitudes lead to different feelings. Your rigid and awfulising attitude led you to feel unhealthily panicky, and your flexible and non-­awfulising attitude led you to feel healthily concerned.

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Brief comparison between a rigid attitude and a flexible attitude In this approach, you briefly help your client to see that when you hold a rigid attitude towards an adversity you experience a UNE, and when you hold a flexible attitude towards the same adversity you experience an HNE.

Windy: So do you know what determines the way we feel? Peter: I’m not sure. Windy: Here’s the way I see it. Imagine that two men are rejected by the woman they love. One feels depressed, can’t adjust to the loss and withdraws from life, while the other feels sad, mourns the loss appropriately and gets on with his life. Now I’m going to outline two attitudes and you tell me which man holds which attitude. OK? Peter: OK. Windy: One man held the attitude: ‘She absolutely should not have rejected me,’ while the other one believed: ‘I really wish she hadn’t rejected me, but that does not mean that it absolutely should not have happened to me.’ Now, which man held which attitude? Peter: The man who felt depressed and withdrew from life held the first attitude and the one who felt sad held the second attitude. Windy: That’s right. This shows two things. First, our feelings are determined not by what happens to us, but by our attitudes towards what happens to us. Second, an unhealthy emotional response is based on a rigid attitude, while a healthy emotional response is based on a flexible attitude.

You can use this brief method to compare a non-­awfulising attitude with an awfulising attitude, an attitude of bearability with an attitude of unbearability and an unconditional acceptance attitude with a devaluation attitude. Let me end this chapter by showing how I could have used the brief comparison method to teach Peter the difference between an unconditional self-­acceptance attitude and a self-­devaluation attitude. Brief comparison between a self-­depreciation attitude and an unconditional self-­acceptance attitude In this approach, you briefly help the client to see that when you hold a self-­devaluation attitude towards an adversity you experience a UNE, and when you hold an unconditional self-­acceptance attitude towards the same adversity you experience an HNE.

Windy: So, do you know what determines the way we feel? Peter: I’m not sure. Windy: Here’s the way I see it. Imagine that two men are rejected by the woman they love. One feels depressed, can’t adjust to the loss and withdraws from life, while the other feels sad, mourns

50

Peter: OK. Windy: One man held the attitude: ‘This rejection proves that I am a worthless loser,’ while the other one held the attitude: ‘This rejection is painful, but is not a reflection of my worth as a person. I am the same person whether I am accepted or rejected.’ Now, which man held which attitude? Peter: The man who felt depressed and withdrew from life held the first attitude and the one who felt sad held the second attitude.

TEACHING THE ABCs OF REBT

the loss appropriately and gets on with his life. Now I’m going to outline two attitudes and you tell me which man holds which attitude. OK?

Windy: That’s right. This shows two things. First, our feelings are determined not by what happens to us, but by our attitudes towards what happens to us. Second, an unhealthy emotional response is based on a self-­devaluation attitude, while a healthy emotional response is based on an unconditional self-­acceptance attitude. So it wasn’t being rejected that led to the first man’s depression; rather, it was his rejection of himself.

In role-­play, practise teaching your partner the difference between the two types of attitudes using the brief comparison method. Keep your focus on one attitude pairing at a time. Repeat the role-­ play in order to gain practice using this method to teach the difference between (a) a rigid attitude and a flexible attitude, (b) an awfulising attitude and a non-­awfulising attitude, (c) an attitude of unbearability and an attitude of bearability and (d) a self-­devaluation attitude and an unconditional self-­acceptance attitude. When using the brief comparison method try to generate alternative hypothetical situations in addition to the rejection example shown here. It can be useful to have several examples at your disposal so you can choose one that you think is likely to resonate with your client. Record the role-­play and ask your REBT trainer for feedback.

In teaching clients the ABCs of REBT it is important to distinguish clearly between HNEs and UNEs. In the following chapter, I will discuss more fully how to make this distinction with clients.

51

Distinguishing between healthy and unhealthy negative emotions I first trained in REBT (or RET, as it was known in those days) in 1977. At that time the distinction ­between healthy negative emotions (HNEs) and unhealthy negative emotions (UNEs) was present in REBT theory, but was not particularly emphasised. Since that time I have come to realise the central place this distinction occupies in the theory and practice of REBT and how important it is to teach it to clients early in the therapeutic process. In this chapter, I will provide a diagrammatic summary of the eight major UNEs and their healthy counterparts (see Table 4.1). In doing so, I will review the inferences, attitudes, cognitive consequences and action tendencies that are associated with each healthy and unhealthy pairing. It is crucial that you understand the factors that help differentiate between HNEs and UNEs before explaining these distinctions to your clients. After providing the diagrammatic summary and reviewing briefly each component I will demonstrate how to introduce some of these distinctions to clients by using illustrative therapist–client dialogue. Finally, I will suggest an exercise that you can do in small training groups to become personally and professionally more familiar with the distinctions between HNEs and UNEs. This exercise will also help you to practise assessing the emotional problems of your fellow trainees before you do so with your clients.

XX HNEs and UNEs: a diagrammatic summary

D i s t i n g u i s h i n g b e t w e e n h e a lt h y a n d   u n h e a lt h y n e g at i v e e m ot i o n s

◀   C HA P TE R F OU R   ▶

Table 4.1 presents a comprehensive diagrammatic summary of the major distinctions between HNEs and UNEs. You will note that there are eight pairs, with the UNE listed first. Please note that I have used the names of emotions as I currently use them in REBT theory. Different REBT therapists may use different words to describe the same emotions. For example, some use the term ‘annoyance’ for healthy anger. Also, as I will presently discuss, clients bring to therapy their own emotional terminology and may well not understand the REBT distinctions just by being introduced to the REBT emotional terminology. Your tasks at this point are to discover your client’s emotional terminology, to explain the REBT version and to negotiate a shared language which reflects the distinctions between HNEs and UNEs as they are made in REBT theory. This does not necessarily involve using REBT terminology. I jokingly explain to trainees that it is acceptable to use the words ‘fish’ and ‘chips’ to distinguish between what REBT theory calls ‘anxiety’ and ‘concern’ as long as you and your client understand that ‘fish’ has the inferences, rigid and extreme attitudes, behaviour and action tendencies and subsequent thinking that are associated with what REBT calls ‘anxiety’ and that the term ‘chips’ has the inferences, flexible and

Fundamentals of Rational Emotive Behaviour Therapy: A Training Handbook, Third Edition. Windy Dryden. © 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.

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Table 4.1  Eight Unhealthy and Healthy Negative Emotions with Adversities, Basic Attitudes and Associated Behaviour and Thinking Anxiety vs Concern Adversity

You are facing a threat to your personal domain

Basic attitude

Rigid and extreme

Flexible and non-­extreme

Emotion

Anxiety

Concern

Behaviour/ action tendencies

▪▪

You avoid the threat

▪▪

You withdraw physically from the threat

▪▪ ▪▪

▪▪

You distract yourself from the threat by engaging in other activity

▪▪

You keep checking on the current status of the threat hoping to find that it has disappeared or become benign

▪▪

You seek reassurance from others that the threat is benign

▪▪

You seek support from others so that if the threat happens they will handle it or be there to rescue you

▪▪

You over-­prepare in order to minimise the threat happening or so that you are prepared to meet it (NB it is the over-­preparation that is the problem here)

▪▪

You tranquilise your feelings so that you don’t think about the threat

▪▪

You overcompensate for feeling vulnerable by seeking out an even greater threat to prove to yourself that you can cope

Subsequent thinking

▪▪

You face up to the threat without using any safety-­seeking measures

You ward off the threat (e.g., by rituals or superstitious behaviour)

▪▪

You take constructive action to deal with the threat

You try to neutralise the threat (e.g., by being nice to people of whom you are afraid)

▪▪

You seek support from others to help you face up to the threat and then take constructive action by yourself rather than rely on them to handle it for you or to be there to rescue you

▪▪

You prepare to meet the threat but do not over-­prepare

Threat-­exaggerated thinking ▪▪

You overestimate the probability of the threat occurring

▪▪

You are realistic about the probability of the threat occurring

▪▪

You underestimate your ability to cope with the threat

▪▪

You view the threat realistically

▪▪

You ruminate about the threat

▪▪

You realistically appraise your ability to cope with the threat

▪▪

You create an even more negative threat in your mind

▪▪

▪▪

You magnify the negative consequences of the threat and minimise its positive consequences

You think about what to do concerning dealing with threat constructively rather than ruminate about the threat

▪▪

You have more task-­relevant thoughts than in anxiety

▪▪

You have more task-­irrelevant thoughts than in concern

▪▪

You picture yourself dealing with the threat in a realistic way

Safety-­seeking thinking

54

▪▪

You withdraw mentally from the threat

▪▪

You try to persuade yourself that the threat is not imminent and that you are ‘imagining’ it

▪▪

▪▪

▪▪ ▪▪

You think in ways designed to reassure yourself that the threat is benign or, if not, that its consequences will be insignificant You distract yourself from the threat (e.g., by focusing on mental scenes of safety and well-­being) You over-­ prepare mentally in order to minimise the threat happening or so that you are prepared to meet it (NB once again it is the over-­preparation that is the problem here) You picture yourself dealing with the threat in a masterful way You overcompensate for your feeling of vulnerability by picturing yourself dealing effectively with an even bigger threat Depression vs Sadness

Adversity

▪▪

▪▪ ▪▪

Basic attitude

You have experienced a loss from the sociotropic (an investment in interpersonal relationships) and/or autonomous realms of your personal domain You have experienced failure within the sociotropic and/or autonomous realms of your personal domain You or others have experienced an undeserved plight

Rigid and extreme

Emotion

Depression

Behaviour/ action tendencies

▪▪

▪▪

▪▪ ▪▪

▪▪

You become overly dependent on and seek to cling to others (particularly in sociotropic depression) You bemoan your fate or that of others to anyone who will listen (particularly in pity-­based depression) You create an environment consistent with your depressed feelings You attempt to terminate feelings of depression in self-­destructive ways You either push away attempts to comfort you (in autonomous depression) or use such comfort to reinforce your dependency (in sociotropic depression) or your self-­or other-­pity (in pity-­based depression)

Flexible and non-­extreme Sadness ▪▪

▪▪

▪▪ ▪▪

You seek out reinforcements after a period of mourning (particularly when your inferential theme is loss) You express your feelings about the loss, failure or undeserved plight and talk in a non-­complaining way about these feelings to significant others You create an environment inconsistent with depressed feelings You allow yourself to be comforted in a way that helps you to express your feelings of sadness and mourn your loss

D i s t i n g u i s h i n g b e t w e e n h e a lt h y a n d   u n h e a lt h y n e g at i v e e m ot i o n s

▪▪

(Continued)

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Table 4.1  (Continued) Basic attitude

Rigid and extreme

Flexible and non-­extreme

Emotion

Depression

Subsequent thinking

▪▪

You see only negative aspects of the loss, failure or undeserved plight

▪▪

▪▪

You think of other losses, failures and undeserved plights that you (and in the case of the latter, others) have experienced

You are able to recognise both negative and positive aspects of the loss or failure

▪▪

You think you are able to help yourself

▪▪

You think you are unable to help yourself (helplessness)

▪▪

You look to the future with hope

▪▪

You only see pain and blackness in the future (hopelessness)

▪▪

You see yourself being totally dependent on others (in autonomous depression)

▪▪

You see yourself as being disconnected from others (in sociotropic depression)

▪▪

You see the world as full of undeservedness and unfairness (in plight-­ based depression)

▪▪

You tend to ruminate concerning the source of your depression and its consequences

Sadness

Guilt vs Remorse Adversity

▪▪

You have broken your moral code

▪▪

You have failed to live up to your moral code

▪▪

You have hurt someone’s feelings

Basic attitude

Rigid and extreme

Flexible and non-­extreme

Emotion

Guilt

Remorse

Behaviour/ action tendencies

▪▪ ▪▪ ▪▪ ▪▪ ▪▪ ▪▪ ▪▪

You escape from the unhealthy pain of guilt in self-­defeating ways You beg forgiveness from the person you have wronged You promise unrealistically that you will not ‘sin’ again You punish yourself physically or by deprivation You defensively disclaim responsibility for wrongdoing You make excuses for your behaviour You reject offers of forgiveness

▪▪

▪▪ ▪▪

▪▪ ▪▪ ▪▪

▪▪

56

You face up to the healthy pain that accompanies the realisation that you have ‘sinned’ You ask, but do not beg, for forgiveness You understand the reasons for your wrongdoing and act on your understanding You atone for the ‘sin’ by taking a penalty You make appropriate amends You do not make excuses for your behaviour or enact other defensive behaviour You accept offers for forgiveness

▪▪

You conclude that you have definitely committed the ‘sin’

▪▪

▪▪

You assume more personal responsibility than the situation warrants

You take into account all relevant data when judging whether or not you have ‘sinned’

▪▪

You assume an appropriate level of personal responsibility

▪▪

You assign far less responsibility to others than is warranted

▪▪

You assign an appropriate level of responsibility to others

▪▪

You dismiss possible mitigating factors for your behaviour

▪▪

You take into account mitigating factors

▪▪

You only see your behaviour in a guilt-­related context and fail to put it into an overall context

▪▪

You put your behaviour into an overall context

▪▪

You think you may be penalised rather than receive ‘retribution’

▪▪

You think that you will receive ‘retribution’ Shame vs Disappointment

Adversity

▪▪

Something highly negative has been revealed about you (or about a group with whom you identify) by yourself or by others

▪▪

You have acted in a way that falls very short of your ideal

▪▪

Others look down on or shun you (or a group with whom you identify) or you think that they do

Basic attitude

Rigid and extreme

Flexible and non-­extreme

Emotion

Shame

Disappointment

Behaviour/ action tendencies

▪▪

You remove yourself from the ‘gaze’ of others

▪▪

You continue to participate actively in social interaction

▪▪

You isolate yourself from others

▪▪

▪▪

You save face by attacking others who have ‘shamed’ you

You respond positively to attempts of others to restore social equilibrium

▪▪

You defend your threatened self-­esteem in self-­defeating ways

▪▪

You ignore attempts by others to restore social equilibrium

▪▪

You overestimate the negativity of the information revealed

▪▪

▪▪

You overestimate the likelihood that the judging group will notice or be interested in the information

You see the information revealed in a compassionate self-­ accepting context

▪▪

▪▪

You overestimate the degree of disapproval you (or your reference group) will receive

You are realistic about the likelihood that the judging group will notice or be interested in the information revealed

▪▪

▪▪

You overestimate how long any disapproval will last

You are realistic about the degree of disapproval self (or reference group) will receive

▪▪

You are realistic about how long any disapproval will last

Subsequent thinking

D i s t i n g u i s h i n g b e t w e e n h e a lt h y a n d   u n h e a lt h y n e g at i v e e m ot i o n s

Subsequent thinking

(Continued)

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Table 4.1  (Continued) Basic attitude

Rigid and extreme

Emotion

Shame

Flexible and non-­extreme Disappointment Hurt vs Sorrow

Adversity

▪▪

Others treat you badly (and you think you do not deserve such treatment)

▪▪

You think that the other person has devalued your relationship (i.e., someone indicates that their relationship with you is less important to them than the relationship is to you)

Basic attitude

Rigid and extreme

Flexible and non-­extreme

Emotion

Hurt

Sorrow

Behaviour/ action tendencies

▪▪

You stop communicating with the other person

▪▪

You communicate your feelings to the other person directly

▪▪

You sulk and make obvious you feel hurt without disclosing details of the matter

▪▪

You request that the other person acts in a fairer manner towards you

▪▪

You indirectly criticise or punish the other person for their offence

▪▪

▪▪

You tell others how badly you have been treated, but don’t take any responsibility for any contribution you may have made to this

You discuss the situation with others in a balanced way, focusing on the way you have been treated and taking responsibility for any contribution you may have made to this

▪▪

You overestimate the unfairness of the other person’s behaviour

▪▪

▪▪

You think that the other person does not care for you or is indifferent to you

You are realistic about the degree of unfairness in the other person’s behaviour

▪▪

▪▪

You see yourself as alone, uncared for or misunderstood

You think that the other person has acted badly rather than demonstrating lack of caring or indifference

▪▪

You tend to think of past ‘hurts’

▪▪

▪▪

You think that the other person has to make the first move towards you and you dismiss the possibility of making the first move towards that person

You see yourself as being in a poor situation, but still connected to, cared for by and understood by others not directly involved in the situation

▪▪

If you think of past ‘hurts’ you do so with less frequency and less intensity than when you feel hurt

▪▪

You are open to the idea of making the first move towards the other person

Subsequent thinking

Unhealthy anger vs Healthy anger Adversity

58

▪▪

You think that you have been frustrated in some way or your movement towards an important goal has been obstructed in some way

▪▪

Someone has treated you badly

▪▪

Someone has transgressed one of your personal rules

▪▪

You have transgressed one of your own personal rules

▪▪

Someone or something has threatened your self-­esteem or disrespected you

Rigid and extreme

Flexible and non-­extreme

Emotion

Unhealthy anger

Healthy anger

Behaviour/ action tendencies

▪▪

You attack the other(s) physically

▪▪

You assert yourself with the other(s)

▪▪

You attack the other(s) verbally

▪▪

▪▪

You attack the other(s) passive-­aggressively

You request, but do not demand, behavioural change from the other(s)

▪▪

You displace the attack on to another person, animal or object

▪▪

▪▪

You withdraw aggressively

You leave an unsatisfactory situation non-­ aggressively after taking steps to deal with it

▪▪

You recruit allies against the other(s)

▪▪

You overestimate the extent to which the other(s) acted deliberately

▪▪

▪▪

You see malicious intent in the motives of the other(s)

You think that the other(s) may have acted deliberately, but you also recognise that this may not have been the case

▪▪

You see yourself as definitely right and the other(s) as definitely wrong

▪▪

You are able to see the point of view of the other(s)

▪▪

You have fleeting rather than sustained thoughts to exact revenge

▪▪

You are unable to see the point of view of the other(s)

▪▪

▪▪

You plot to exact revenge

▪▪

You ruminate about the other’s behaviour and imagine coming out on top

You think that other(s) may have had malicious intent in their motives, but you also recognise that this may not have been the case

▪▪

You think that you are probably rather than definitely right and the other(s) are probably rather than definitely wrong

Subsequent thinking

D i s t i n g u i s h i n g b e t w e e n h e a lt h y a n d   u n h e a lt h y n e g at i v e e m ot i o n s

Basic attitude

Unhealthy jealousy vs Healthy jealousy (or relationship concern) Adversity

▪▪

A threat is posed to your relationship with your partner from a third person.

▪▪

A threat is posed by uncertainty you face concerning your partner’s whereabouts, behaviour or thinking in the context of the first threat

Basic attitude

Rigid and extreme

Flexible and non-­extreme

Emotion

Unhealthy jealousy

Healthy jealousy (relationship concern)

Behaviour/ action tendencies

▪▪

You seek constant reassurance that you are loved

▪▪

You allow your partner to initiate expressing love for you without prompting them or seeking reassurance once they have done so (Continued)

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Table 4.1

(Continued)

Basic attitude

Rigid and extreme

Flexible and non-­extreme

Emotion

Unhealthy jealousy

Healthy jealousy (relationship concern)

Subsequent thinking

▪▪

You monitor the actions and feelings of your partner

▪▪

You search for evidence that your partner is involved with someone else

▪▪

You allow your partner freedom without monitoring their feelings, actions and whereabouts

▪▪

You attempt to restrict the movements or activities of your partner

▪▪

You set tests which your partner has to pass

▪▪

You allow your partner to show natural interest in other people without setting tests

▪▪

You retaliate for your partner’s presumed infidelity

▪▪

You communicate your concern for your relationship in an open and non-­blaming manner

▪▪

You sulk

▪▪

You exaggerate any threat to your relationship that does exist

▪▪

You think the loss of your relationship is imminent

▪▪

You tend not to exaggerate any threat to your relationship that does exist

▪▪

You misconstrue your partner’s ordinary conversations with relevant others as having romantic or sexual connotations

▪▪

You do not misconstrue ordinary conversations between your partner and other people

▪▪

You construct visual images of your partner’s infidelity

▪▪

You do not construct visual images of your partner’s infidelity

▪▪

If your partner admits to finding another person attractive, you think that they find that person more attractive than you and that they will leave you for this other person

▪▪

You accept that your partner will find others attractive but you do not see this as a threat

Unhealthy envy vs Healthy envy

 

Adversity

60

▪▪

Another person possesses and enjoys something desirable that you do not have

Basic attitude

Rigid and extreme

Flexible and non-­extreme

Emotion

Unhealthy envy

Healthy envy

Behaviour/ action tendencies

▪▪

You disparage verbally the person who has the desired possession to others

▪▪

You disparage verbally the desired possession to others

▪▪

If you had the chance you would take away the desired possession from the other (either so that you will have it or that the other is deprived of it)

▪▪

If you had the chance you would spoil or destroy the desired possession so that the other person does not have it

▪▪

You strive to obtain the desired possession if it is truly what you want

▪▪

You tend to denigrate in your mind the value of the desired possession and/or the person who possesses it

▪▪

You honestly admit to yourself that you desire the desired possession

▪▪

You try to convince yourself that you are happy with your possessions (although you are not)

▪▪

▪▪

You think about how to acquire the desired possession regardless of its usefulness

You are honest with yourself if you are not happy with your possessions, rather than defensively trying to convince yourself that you are happy with them when you are not

▪▪

▪▪

You think about how to deprive the other person of the desired possession

You think about how to obtain the desired possession because you desire it for healthy reasons

▪▪

▪▪

You think about how to spoil or destroy the other’s desired possession

You can allow the other person to have and enjoy the desired possession without denigrating that person or the possession

▪▪

You think about all the other things the other has that you don’t have

▪▪

You think about what the other has and lacks and what you have and lack

D i s t i n g u i s h i n g b e t w e e n h e a lt h y a n d   u n h e a lt h y n e g at i v e e m ot i o n s

Subsequent thinking

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non-­extreme attitudes, behaviour and action tendencies and subsequent thinking associated with what REBT theory calls ‘concern.’ Adversities at A Looking at Table 4.1 from top to bottom, the first row outlines the major adversity or adversities at A that are associated with both the UNE and the HNE. In therapeutic practice, adversities are most likely to be inferences (see Chapter 1). To help you to understand inferences fully in the context of your client’s emotional experiences, I need to introduce you to the concept of the ‘personal domain’. This concept was first introduced in the mid-­ 1970s by Aaron T. Beck (1976) and refers to the objects – both tangible and intangible – in which a person has an involvement. REBT theory distinguishes between ego-­and comfort-­related aspects of the personal domain, although it does emphasise that these aspects frequently interact. Remember from Chapter 1 that inferences are personally significant hunches about reality that give meaning to it. Inferences go beyond the data at hand and need to be tested out by your client. They may be accurate or inaccurate. If you consider the ‘adversity’ row in Table 4.1, you will note that within each pairing, an HNE and its unhealthy counterpart share the same inference. This makes the REBT position on emotions very clear; that is, inferences contribute to, but do not determine, emotions. Put slightly differently, while inferences are important in determining the flavour of a negative emotion, they do not determine the health of that emotion. For that we need to turn to the parts of the table which outline the types of basic attitudes that lie at the core of each pair of healthy–unhealthy negative emotions. Basic attitudes The next row lists the two types of basic attitudes that feature in the REBT conceptualisation of UNEs and HNEs. On the left are the rigid and extreme attitudes that are at the base or core of UNEs, and on the right are the flexible and non-­extreme attitudes that are at the base or core of HNEs. In Tables 1.2 and 1.4 in Chapter 1, I listed the four types of flexible and non-­extreme attitudes and rigid and extreme attitudes, and I present them here for easy reference. Four Types of Rigid and Extreme Attitudes

Four Types of Flexible and Non-extreme Attitudes

▪▪

Rigid attitudes

▪▪

Flexible attitudes

▪▪

Awfulising attitudes

▪▪

Non-­awfulising attitudes

▪▪

Attitudes of unbearability

▪▪

Attitudes of bearability

▪▪

Self-­devaluation/other-­devaluation/life-­devaluation attitudes

▪▪

Unconditional self-­acceptance/other-­acceptance/ life-­acceptance attitudes

Emotions The next row shows whether the negative emotion listed is unhealthy (on the left) or healthy (on the right). The main way to distinguish between a UNE and an HNE is to look at their effects. According to REBT theory, UNEs about adversities at A are unhealthy in the sense that they do not help your clients to change these adversities if indeed they can be changed, nor do they encourage them to make a constructive adjustment if these adversities cannot be changed. HNEs do encourage productive attempts to change adversities and do facilitate constructive adjustment to adversities that cannot be changed. Also, HNEs aid your clients in their pursuit of their basic goals and purposes, while UNEs impede them in this pursuit.

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The next row lists the behaviours and action tendencies that stem from rigid and extreme attitudes (on the left) and from flexible and non-­extreme attitudes (on the right). When a person holds an attitude towards an adversity, they experience an urge to act in a certain way. I call these urges ‘action tendencies’. However, it is far from inevitable that your client will act in accordance with a particular action tendency. Let me give an example to illustrate these points. If your client holds a rigid/extreme anxiety-­determining attitude, they will experience a strong tendency to withdraw from the situation in which they are anxious. However, they can go against their action tendency and remain in the situation until their feelings of anxiety dissipate. Indeed, the behavioural principle of exposure requires your client to do just this (Marks, 2005). Encouraging your clients to act against their action tendencies is a core feature of REBT practice after you have helped them to examine and begin the process of changing their rigid and extreme attitudes. Subsequent thinking The final row details the subsequent thinking that stems from rigid and extreme attitudes (on the left) and from flexible and non-­extreme attitudes (on the right). While the adversity-­related inferences listed in the first row of the table give shape to your client’s emotional experience (e.g., when the person faces a threat they will either experience anxiety or concern), the cognitive consequences listed in the final row detail the kinds of thinking that your client engages in while holding different attitudes. As you will see if you inspect the final rows of each emotion pairing carefully, the type of thinking your client engages in as a result of holding rigid and extreme attitudes (i.e., on the left) tends to be skewed and distorted, while the type of thinking they engage in when they are holding flexible and non-­extreme attitudes (i.e., on the right) tends to be realistic and balanced. While your client’s inferences at A are often distorted when they are disturbed and holding rigid/ extreme attitudes, the subsequent thinking that they engage in at C, which is also largely inferential, will be even more distorted and skewed. The reason for this is that your client’s inferences at A trigger their rigid and extreme attitudes at B, while their inferences at C (subsequent thinking) are determined by these rigid and extreme attitudes.

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Behaviours and action tendencies

XX Five approaches to teaching clients the distinction between HNEs and UNEs There are five approaches to helping yourself and your clients differentiate between HNEs and UNEs. Before I list these, I do wish to stress that you can employ these approaches singly or together. As different approaches will be enlightening for different clients, I advise you to become familiar with all of them. Distinguishing between emotional terms (approach 1) Because REBT theory distinguishes between UNEs and their healthy counterparts, in helping your clients to make this distinction in therapy it is important to use agreed terminology which reflects this important difference. There are two ways of doing this. First, you can use the REBT terminology as shown in Table 4.2. This table provides a brief reminder of these terms. One problem that you may experience with taking this tack is that your client brings to therapy their own way of construing emotions, and these constructions may be quite different from the REBT terms. It is quite common, for example, for your client to consider that unhealthy anger and guilt are constructive emotions, and as such they would resist accepting your view that they are unhealthy. In order to

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Table 4.2  Healthy and Unhealthy Negative Emotions: REBT Terminology Unhealthy negative emotions

Healthy negative emotions

▪▪

Anxiety

▪▪

Concern

▪▪

Depression

▪▪

Sadness

▪▪

Guilt

▪▪

Remorse

▪▪

Hurt

▪▪

Sorrow

▪▪

Shame

▪▪

Disappointment

▪▪

Unhealthy anger

▪▪

Healthy anger

▪▪

Unhealthy jealousy

▪▪

Healthy jealousy (relationship concern)

▪▪

Unhealthy envy

▪▪

Healthy envy

clarify the REBT position here, you would need to make use of one or more of the four other approaches described in this section. Another problem with relying solely on REBT terminology is that your client may well consider that HNEs are less intense than their unhealthy counterparts. For example, your client may consider remorse to be less intense than guilt. REBT’s position on this issue is quite different – namely, that this HNE can be very intense and still be constructive. Thus, you can be intensely remorseful at breaking your own moral code without (a) holding a rigid attitude demanding that you absolutely should not have acted in such a manner and (b) condemning yourself as a person for your behaviour. REBT’s theory of negative emotions posits qualitative rather than quantitative differences between HNEs and UNEs, and thus one can be intensely remorseful without feeling guilty. A quantitative approach to negative emotions would place anxiety on a single continuum with differing levels of intensity of this emotion placed on this one continuum. In contrast, a qualitative approach would employ two continua: one for anxiety, the other for concern with increasing levels of intensity of each emotion represented on each continuum. Thus, the quantitative approach does not keenly distinguish between anxiety and concern, while the qualitative approach does. This crucial difference is shown in Table 4.3. Table 4.3  Quantitative and Qualitative Models of Negative Emotions Quantitative model: Increasing levels of anxiety (no clear distinction between anxiety and concern) No anxiety������������������������������������������������������������������ Intense anxiety Qualitative model: (i)  Increasing levels of anxiety (clear distinction between anxiety and concern) No anxiety������������������������������������������������������������������ Intense anxiety (ii)  Increasing levels of concern (clear distinction between anxiety and concern) No concern����������������������������������������������������������������� Intense concern

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Distinguishing between flexible/non-­extreme attitudes and rigid/extreme attitudes (approach 2)  As I have stated several times in this book, REBT theory holds that HNEs stem largely from flexible and non-­ extreme attitudes and UNEs stem largely from rigid and extreme attitudes. It follows therefore that another approach to helping clients distinguish HNEs and UNEs involves referring to this part of REBT theory. For example, in helping your client distinguish between anxiety and concern you will want to point out that anxiety is based largely on rigid and extreme attitudes such as:

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In order to clarify these issues you will need to go beyond mere presentations of different terms and again use one or more of the four other approaches to distinguishing between HNEs and UNEs, to be described presently. The second way of distinguishing between HNEs and UNEs that employs different terms involves eliciting such distinctions from clients themselves. For example, one of your clients may use the terms ‘helpful anxiety’ and ‘unhelpful anxiety’ seemingly to differentiate between what in REBT terminology is known as concern and anxiety. Another of your clients may use the terms ‘furious’ and ‘pissed off’ instead of REBT’s unhealthy anger and healthy anger. As in the first example, many clients use a different qualifier to distinguish between an HNE and its unhealthy counterpart. In the first example, the ‘helpful’ and ‘unhelpful’ qualifiers were used by the client seemingly to denote a distinction between REBT’s anxiety and concern. We say ‘seemingly’ here because without exploring the matter further you will not know whether or not your client’s terms match those used by REBT. Thus, in the example we are considering, in your client’s mind ‘helpful’ anxiety may be much less intense than ‘unhelpful’ anxiety. As explained above and shown in Table 4.3, this represents a quantitative model of negative emotions rather than the qualitative model advocated by REBT theory. The other problem with accepting clients’ emotional terms without exploring the meaning behind them is that these terms may reflect a different perspective on emotions from that put forward by REBT therapists. If you do not find out what your clients mean by their emotional terms then you have no way of discussing with them the problems that may be involved in their conceptualisations. In conclusion, I hope you can see that relying solely on the ‘using different terms’ approach to helping clients distinguish between healthy and unhealthy negative emotions is fraught with problems. Consequently, you will need to employ one or more of the other four approaches to be discussed in this chapter to supplement this terms-­based approach.

▪▪ This threat must not occur. ▪▪ It would be awful if this threat were to occur. ▪▪ I could not bear it if this threat were to occur. And in ego anxiety: ▪▪ If this threat were to materialise, it would prove that I would be worthless. You will also want to point out that concern is based largely on flexible and non-­extreme attitudes such as: ▪▪ I would prefer it if this threat did not occur, but there is no reason why it must not happen. ▪▪ It would be bad if this threat occurred, but it would not be terrible. ▪▪ If this threat occurred, it would be difficult to bear, but I could bear it.

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And in ego concern: ▪▪ I would be a fallible human being if this threat were to occur. It would not prove that I am worthless. Having presented the two different sets of attitudes in the context of the client’s specific problem, you can then ask your client to use these different attitudes to judge whether they were experiencing anxiety or concern. If you use this attitudes-­based approach to helping your client to distinguish between healthy and unhealthy negative emotions, then you can refer back to the example you used to teach them the ABCs of REBT if you have already done so (see Chapter 3), or you can use this approach as a reminder when you do teach your client the ABCs. Distinguishing between action tendencies (approach 3)  As I explained in Chapter  1, when your c­ lient experiences an emotion they have a tendency to act in a number of ways. Because different emotions are associated with different sets of action tendencies, a third approach to teaching your client how to distinguish between HNEs and UNEs is to focus their attention on these different sets of action tendencies. Using the example of helping your client to distinguish between anxiety and concern, you will want to point out that when they are anxious they will tend: ▪▪ to withdraw physically from the threat (i.e., by leaving the situation); ▪▪ to withdraw mentally from the threat (e.g., by changing the subject if they find a topic of conversation threatening); ▪▪ to ward off the threat (e.g., by using obsessive-­compulsive, safety-­seeking behaviour or superstitious behaviour); ▪▪ to tranquilise their feelings (e.g., by the use of alcohol, legal and illegal drugs, food, cigarettes, etc.); and ▪▪ to seek reassurance so that the threat is neutralised, at least in the person’s mind. On the other hand, you will want to explain that concern is associated with a different set of action tendencies. When your client is feeling concern they will tend: ▪▪ to face the threat; and ▪▪ to deal with the threat constructively without engaging in safety-­seeking behaviour. Once you have reviewed the two different sets of action tendencies in the context of your client’s specific problem, you can then ask them once again to use these different action tendencies as a yardstick to judge whether they were experiencing anxiety or concern. Distinguishing between subsequent thinking patterns associated with UNEs and HNEs (approach  4)  Another approach to helping your client to distinguish between healthy and unhealthy negative emotions is to focus their attention on the different ways of thinking associated with the utility of HNEs and UNEs. Continuing the example of teaching your client to distinguish between anxiety and concern, you will want to point out that anxiety has a number of forms of subsequent thinking: ▪▪ Your client will tend to overestimate the negative features of the threat. ▪▪ They will tend to underestimate their ability to cope with the threat.

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▪▪ If they are carrying out a task while they are anxious, they will tend to have more task-­irrelevant than task-­relevant thoughts. On the other hand, you will want to explain that concern has different forms of subsequent thinking: ▪▪ Your client will not tend to overestimate the negative features of the threat. ▪▪ They will tend to have a realistic view of their ability to cope with the threat. ▪▪ When facing the threat, they will not tend to create an even more negative threat in their mind. ▪▪ If they are carrying out a task while they are concerned, they will tend to have more task-­relevant than task-­irrelevant thoughts. Having presented the two forms of subsequent thinking in the context of the client’s specific problem, you can then ask your client to use these different forms of subsequent thinking to judge whether they were experiencing anxiety or concern. Distinguishing between symptoms (approach 5) The final approach to helping your client to distinguish between HNEs and UNEs concerns focusing their attention on the difference in symptoms between the two different types of negative emotions. This is a somewhat problematic approach to use on its own as there is some overlap in symptoms associated with HNEs and UNEs. For example, if you feel anxious you may well experience such symptoms as butterflies in your stomach, dry mouth and sweating. However, you may well experience these symptoms when you feel concerned and not anxious. If you are going to use a symptoms-­based approach to differentiating between HNEs and UNEs, the point to stress with your client is that when they have a UNE (e.g., anxiety) they will experience more disabling symptoms and the degree of disability will be greater than when they have an HNE (e.g., concern). I made the point earlier that it is advisable to use a combination of the five approaches when helping your clients to distinguish between their HNEs and UNEs. I will demonstrate this in an illustrative therapist–client dialogue. But, first, let me summarise the five approaches in Table 4.4.

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▪▪ When facing the threat, they will tend to create an even more negative threat in their mind.

Table 4.4  Five Approaches to Distinguishing Between Healthy and Unhealthy Negative Emotions Approach 1: Distinguishing between emotional terms (Terms-­based approach) Approach 2: Distinguishing between flexible/non-­extreme attitudes and rigid/extreme attitudes (Attitudes-­based approach) Approach 3: Distinguishing between action tendencies (Action-­tendencies-­based approach) Approach 4: Distinguishing between subsequent thinking patterns associated with UNEs and HNEs (Subsequent-­thinking-­based approach) Approach 5: Distinguishing between symptoms (Symptoms-­based approach) 67

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XX Teaching your client to distinguish between a UNE (unhealthy anger) and an HNE (healthy anger): an illustrative dialogue In this dialogue, I am counselling John, who has been referred by his GP for ‘anger management’. It is the second session and I am discussing a recent episode where he felt ‘pissed off’ at work. As will become clear, I am not clear at the outset whether by this he meant healthy anger or unhealthy anger. In the following part of the session I am attempting to clarify both for myself and for John whether his negative emotion was healthy or unhealthy. As you will discover, by ‘pissed off’ John meant unhealthy anger. As I will discuss later, it is important to help your client set goals which reflect healthy negative emotional responses to adversities, and this is particularly important when the emotion is anger. However, I will not discuss this issue here with John.

Windy: So, if I understand you correctly, you felt ‘pissed off’ when your boss did not put you on the Gwilliam account. Is that right? John: Yes, that’s right. Windy: Now, in the therapy that I practise, we make an important distinction between what we call healthy and unhealthy negative emotions. The former are constructive responses to negative life events, while the latter are not so constructive. I’m not sure whether ‘pissed off’ is a healthy or an unhealthy response to the Gwilliam episode. Will you bear with me while I ask you a few questions to help us both become clearer on this issue? John: OK. Windy: More specifically, I want to discover whether you felt unhealthily angry or healthily angry. Does that distinction mean anything to you? [This is an Approach 1 intervention.] John: Not really. Windy: OK, let me explain. If you were healthily angry in this situation, you would hold a set of attitudes similar to the following: ▪▪ I really want my boss to put me on the Gwilliam account, but he doesn’t have to do so. ▪▪ It’s really unfortunate that my boss hasn’t put me on this account, but it isn’t terrible. ▪▪ I can bear being deprived in this way, although it is difficult to bear. ▪▪ My boss isn’t a bastard for depriving me of this opportunity, just a fallible human being who has done what I consider the wrong thing. However, if you were unhealthily angry in this situation, you would hold a different set of attitudes like the following: ▪▪ My boss absolutely should put me on the Gwilliam account. ▪▪ It’s terrible that he hasn’t.

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▪▪ He is a bastard for depriving me of this opportunity. Now which set of attitudes best accounted for your pissed off feeling at the time? [This is an Approach 2 intervention.] John: Put like that, I was unhealthily angry, because I thought that he was a bastard who shouldn’t have treated me like that. Windy: Right, but let’s make doubly sure by looking at what you wanted to do in the situation. Now, if you were unhealthily angry in the situation, you would have felt like attacking your boss physically or verbally; if not directly you would have felt drawn to getting back at him indirectly; or you would have felt like storming out. However, if you were healthily angry, your inclination would have been to assert yourself with him in an open and reasoned manner. [This is an Approach 3 intervention.] John: Well, that clinches it, then. I wanted to knock his block off. Windy: So, it sounds as if you recognise that you were unhealthily angry rather than healthily angry. Do you generally refer to feeling ‘pissed off’ when you are angry? John: I’ve never thought about it before. . . No, I use it quite loosely. Windy: So, because it is important to distinguish between a healthy negative emotion like healthy anger and an unhealthy negative emotion like unhealthy anger, we need to use terms to reflect this distinction. Does it make sense to you to use the terms ‘unhealthy anger’ and ‘healthy anger’ as I have described them or can you think of more apt terms? John: Yes, that sounds reasonable.

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▪▪ I can’t bear the deprivation.

Windy: So, we’ll use this distinction throughout our work together.

In this segment, I used a combination of three approaches to ascertain that John was unhealthily angry rather than healthily angry when he said he was ‘pissed off ’. First, I used the terms-­based approach (Approach 1). Here, I introduced the REBT terms, unhealthy anger and healthy anger, to see if  John could see the difference between them. When he said that he could not, I used the attitudes-­based approach (Approach 2) and outlined the likely rigid and extreme attitudes that underpinned his ‘pissed off ’ feeling if this was unhealthy anger and the likely flexible and non-­extreme attitudes that ­underpinned this feeling if it turned out to be healthy anger. When John said that he related most to the rigid and extreme attitudes, thus confirming that he was unhealthily angry, I used the action-­tendencies-­based approach (Approach 3) to c­ heck. Finally, I returned to the terms-­based approach to agree on a shared language when discussing anger-­related issues with John during counselling.

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How can you become more skilled at explaining the differences between healthy and unhealthy negative emotions to your clients? First, familiarise yourself with each of these different approaches. Second, pair up with a trainee colleague and, using a role-­play format, practise explaining the differences between healthy and unhealthy negative emotions by employing arguments based on the five approaches. Record the role-­play and play it to your REBT trainer or supervisor for feedback.

Becoming proficient at this skill will stand you in good stead when you come to assess your clients’ problems using the ABC framework, a subject to which I now turn.

Being specific in the assessment process When your clients discuss their problems at the outset of therapy they often do so in general terms. It is difficult to assess clients’ problems when they are couched in general terms. REBT theory states that people make themselves disturbed about specific events because they hold specific rigid and extreme attitudes towards these events. These specific rigid/extreme attitudes may reflect more general, core rigid/extreme attitudes, but when your clients disturb themselves, it is in specific situations and because they hold specific rigid/extreme attitudes towards specific adversities in those specific situations. Therefore, it is important for you to encourage your clients to provide specific examples of their emotional problems. Doing so will provide both of you with the information you require to carry out an accurate assessment of these problems. However, it is also important to give your client an opportunity to talk about their problems in their own way, at least until they consider that you have listened to them and shown that you have understood them from their own frame of reference. As you do this you can begin to construct an overall picture of the problems they are experiencing in their life. On more advanced courses in REBT, we devote quite a bit of time to the development of a problem list, on which your client lists the problems they wish to deal with during therapy. As such, this topic is beyond the scope of this introductory book (see Beck, 2021).

Being specific in the assessment process

◀  CHAPTER FI V E  ▶

XX Select a nominated problem After you have given your client an opportunity to talk about their problems in their own way, you will want to encourage them to discuss in greater depth the problem they want to tackle first in therapy. As I mentioned in Chapter 2, I refer to this as the nominated problem. This nominated problem should be an emotional problem rather than a practical problem (Dryden, 2021a).

Nominated Problem – The problem that you and your client have agreed to focus on in therapy

Fundamentals of Rational Emotive Behaviour Therapy: A Training Handbook, Third Edition. Windy Dryden. © 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.

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You need to explain to your client that you are going to assess this nominated problem and thus you will need to stay focused on it until you have adequately assessed it and helped your client to deal with it. Guard against switching from problem to problem. Select and assess a specif ic example of your client’s nominated problem To help you keep focused and to gain the specific information you need in order to assess the problem thoroughly, encourage your client to provide a specific example of their nominated problem. This specific example might be: ▪▪ a recent example of the nominated problem ▪▪ a typical example of the nominated problem ▪▪ a vivid example of the nominated problem or ▪▪ a predicted future example of the nominated problem. What is important is that the problem is specific enough to provide you with a clear A and a definite unhealthy negative emotion at C. If you are successful in doing so, it makes assessing your client’s rigid and extreme attitudes at B relatively straightforward. However, in all probability, your client will, in the course of the assessment of this specific example of their problem, move quite easily to a more general or abstract level of discourse. Guard against any tendency that you have to move to that general level of exploration. Don’t hesitate to interrupt your client and encourage them to return to the specific example at hand. Explain the reason for your interruption and intervention. You may have to interrupt your client several times before they get the point. Don’t hesitate to do this, but do so politely and with tact. As many therapists have difficulty interrupting clients, let me outline what I say to clients in advance and particularly to those whom I think I will have to interrupt.

Windy: As it is important that we keep focused on the problem that you want help with in therapy, sometimes I may have to interrupt you. This is to help us both keep to the focus once we have agreed it. Client: Yes, that’s fine. Windy: Good. From your perspective how can I best interrupt you? Client: Just say that you want to interrupt me and that’s fine. Windy: OK, I’ll do that.

You may also have to guard against your own tendency to move the client away from an assessment of the specific example of their problem to a more general assessment of the problem. Remember that when you assess a specific example of your client’s problem this occurs at a specific time, in a specific setting and with specific people present.

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You can do a similar exercise when your ‘client’ moved you away from the specific to the general and you did not bring them back to the specific example at hand.

In this brief chapter, I have made the point that your initial work with a client needs to be specific, particularly when you are working with a client to assess their nominated problem. In the next three chapters, I will show you how to use the concept of specificity when you apply the ABC framework to assess the client’s nominated problem. In doing so, I will first discuss assessing the client’s most disturbed emotion at C. Then, once you have identified C, you can use this information to identify the adversity at A. Having identified A and C, you are in a very strong position to identify B. By using the order CAB to structure the following three chapters, I am following what REBT therapists most often do in therapy.

Being specific in the assessment process

As you may not realise that you are, in fact, moving your client away from the specific to the general, we recommend that you record assessment sessions with some of your fellow trainees in a peer counselling session. Identify occasions when you moved your ‘client’ from the specific to the general. Then, devise interventions that you could have made that would have helped you to stay specific.

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Assessing C

ASSESSING C

◀ CHAPTER SIX  ▶

Once you have become skilled in REBT, you will be able to assess your clients’ problems whether they supply you with emotional Cs, behavioural Cs or cognitive Cs. However, at this stage of your career as an REBT therapist, you will need to concentrate on being able to assess their emotional C’s, and as such in this chapter I will show you how to assess these emotional Cs. In doing so I will (a) encourage you to avoid A → C language in assessing C; (b) tell you how to respond when your client believes that a healthy negative emotion (HNE) is unhealthy; (c) help you to deal with vague Cs; (d) advise you what to do when your client’s C is really an A; and (e) suggest ways of intervening when your client gives you an extended statement when you ask for a specific C.

XX Avoid A → C language in assessing C When asking questions about how your client feels in a specific situation, be careful not to use what we call in REBT A → C language. When you use A → C language you reinforce the idea in your client’s mind that A really does cause C. As this is the antithesis to the REBT position and runs counter to what you may have taught your client if you have already introduced the ABC model to them (see Chapter 3), by employing A → C language you will be giving your client conflicting and confusing messages. Here are some typical A → C questions that trainees ask at the beginning of their training in REBT: ▪▪ How did that make you feel? ▪▪ What feeling did that produce in you? ▪▪ Did that anger you? ▪▪ What feeling did that give you? ▪▪ What feeling did that provoke (or evoke) in you? ▪▪ What emotion did that give rise to? ▪▪ How did that lead you to feel? I trust you can see that all these questions either explicitly state or strongly imply an A-­causes-­C theory of human emotion. For example, the question, ‘How did that make you feel?’ makes explicit that you think that ‘that’ (an unspecified event) can make your client feel something without recourse to any mediating variable (i.e., your client’s attitudes). Therefore, A (‘that’) is deemed to cause C (your client’s feelings). How can you enquire about your client’s feelings without explicitly stating or implying an A → C position? Let’s examine two questions which avoid taking such a position. Fundamentals of Rational Emotive Behaviour Therapy: A Training Handbook, Third Edition. Windy Dryden. © 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.

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When that happened, how did you feel? In this question, you are putting forward a correlational relationship between A (the adversity), ‘When that happened’, and C (your client’s feeling), ‘How did you feel?’ In doing so, you neither make explicit nor imply a causal relationship between A and C. How did you feel about that? In this question, you again advance a correlational relationship between C (‘How did you feel. . .’) and A (‘. . . about that?’). However, the word ‘about’ makes it clear that your client’s feeling is closely related to the event without implying that the former is caused by the latter. I recommend, therefore, that when you ask your clients about their feelings about A that you include the word ‘about’ in your question. If you do, you will find it difficult to posit an A → C model of emotions, and you will make it clear that the client’s C is closely related to the A in question.

Here are a number of things that you can do to guard against asking A → C questions. 1. Become aware of A → C phrases in people’s language. Watch soap operas on TV, for example, and write down phrases that explicitly state or strongly imply an A-­causes-­C view of emotions. 2. Reformulate these A → C phrases into phrases that state a correlational view of human emotions. 3. Pair up with a trainee colleague and conduct a role-­play of a counselling session. Have your colleague play the role of a client who makes numerous A → C statements. Correct your ‘client’ every time you identify an A → C statement. 4. Record the session and in replay listen for any A → C client statements that you missed. Also, listen closely to your reformulations of these statements and evaluate your responses. Improve your phrasing as needed. 5. Get used to using A → C correlational statements and questions in your everyday speech. Correct yourself whenever you make an A → C causal connection in your speech. Notice A → C phrases in the speech patterns of others with whom you converse. Reformulate them in your mind, but don’t correct others on this point. Some trainees become overenthusiastic and correct A → C language whenever they hear it. In my view, this is an unwarranted intrusion into the social conventions of everyday conversation and I don’t recommend that you do it. 6. Record your therapy sessions and listen to them carefully for instances of A → C thinking in your statements and questions. Correct these in your mind. Also listen to instances of A → C thinking in your clients’ language. If you did not correct the most important of these, determine which were the most important to correct and think about how you could have done so. It is important to be circumspect. It is legitimately irritating for clients to be corrected every time they utter an A → C statement. You need to correct the most salient of these statements; you don’t need to correct each and every one of them! 7. Take to supervision or training your ongoing difficulties in dealing with A → C statements, either your own or your clients’.

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In Chapter 4, I stressed the importance of helping your client to distinguish between an HNE and an unhealthy negative emotion (UNE). This is very important to bear in mind while assessing C. If your client has an HNE about an adversity, then this is not targeted for change in REBT as it is regarded as a constructive response to an aversive situation. Explaining the above to your client is useful because it helps to reveal one of two related situations. First, it brings to light the idea held by some clients that calmness or the absence of feeling is a desirable and healthy response to an adversity at A. At this point you can explain to your client that in order for them to be calm in the face of adversity, they would have to have an attitude of indifference about the adversity. Taking the example of John discussed in Chapter  4: he would have to believe ‘I don’t care whether or not my boss puts me on the Gwilliam account’ in order to feel calm about his boss’s behaviour. Put like this, your client will generally understand the unrealistic nature of denying their healthy desires and no longer regard their HNE as problematic. Explaining the constructive nature of an HNE may also reveal that your client has a second-­order problem. Here, your client has a UNE about what is a healthy negative response. For example, Dina was intensely but healthily angry about being refused permission to go on leave. She was, however, unhealthily angry with herself for getting so healthily angry. Although her anger was healthy, Dina felt unhealthily angry about being healthily angry. Dina held the rigid attitude that she absolutely should not have such strong feelings about being refused leave. She allowed herself to experience only mild or moderate negative feelings, but believed that such strong feelings as hers were not acceptable. Helping clients like Dina to see that HNEs can be strong is sometimes sufficient here. When it is not, then the real emotional problem is your client’s secondary problem, which is then targeted for change.

ASSESSING C

XX When your client believes that an HNE is unhealthy

With a fellow trainee, role-­play a scenario in which your client construes an HNE as unhealthy. Help your partner to understand the functional cognitive consequences and action tendencies associated with the HNE. Refer to Table 4.1 (pp. 54–61) to help you.

XX When your client’s C is vague When you ask your client for their feelings about an adversity at A, they may well give you a vague feeling statement in reply. Here are some of the responses that clients may provide when you ask them how they felt about the adversities in their lives: ▪▪ I felt upset ▪▪ I felt miserable ▪▪ I felt bad ▪▪ I felt tense ▪▪ I felt bothered ▪▪ I felt hot and bothered ▪▪ I felt jittery ▪▪ I felt down

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▪▪ I felt devastated ▪▪ I felt pissed off ▪▪ I felt blue ▪▪ I felt jumpy ▪▪ I felt gutted There are two problems with the feeling statements listed above. First, it is unclear whether they refer to HNEs or their paired unhealthy counterparts. You may think that ‘devastated’ may refer to a UNE, but without further exploration you cannot be certain. Second, it is unclear in many cases to which pair of emotions the feeling statement refers. Take the word ‘upset’ as an example. Leaving aside the issue concerning whether this refers to an HNE or a UNE, and assuming for the sake of discussion that it is an unhealthy emotion, what kind of emotion is it? Is it an anxious upset, a depressed upset or an angry upset? The answer is that we just don’t know. Whenever your client’s feeling statement is vague, it is very important that you try to clarify it. In Chapter 4, I showed how I clarified John’s vague feeling of being pissed off. If you recall from that chapter I mentioned that in addition to the terms you and your clients may use to refer to emotional states, you can utilise the following information in clarifying whether a negative emotion is healthy or unhealthy: ▪▪ the type of attitude your client holds (flexible/non-­extreme or rigid/extreme); ▪▪ their behaviours or action tendencies; ▪▪ the thinking they engaged in subsequent to holding their attitude; and ▪▪ their symptoms. You can also use such information to clarify your client’s vague negative emotion when you are unsure about its nature (e.g., whether it is anxiety/concern, depression/sadness, guilt/remorse, etc.). When you are unsure about the nature of your client’s negative emotion, irrespective of its health, you can also refer to their adversity-­related inferences for clues. Thus, if your client is talking about a threat to their personal domain, they are likely to be anxious or concerned; if they are discussing hurting the feelings of a significant other, they are likely to feel guilt or remorse. Becoming very familiar with which pairs of negative emotions are associated with which adversity-­related inferences will be enormously useful in your quest to identify your client’s specific UNE. Having at your fingertips the knowledge outlined in Table 4.1 is about the best preparation you can undertake for assessing your client’s Cs.

XX When your client’s C is really an A When you ask your client about their emotions about an adversity, they may reply with an inference rather than an emotion. For example, your client may say the following: ▪▪ I felt rejected ▪▪ I felt punished ▪▪ I felt betrayed ▪▪ I felt abandoned ▪▪ I felt used

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▪▪ I felt frustrated If you inspect these statements carefully you will note that none of them represents actual emotions. We do not have an emotion called ‘rejection’ or one called ‘used’, for example. Rather, we have emotions about the inference that we have been rejected or used at A. When your client expresses a C that is really an inferred A, how can you best respond? The following is a constructed therapist–client dialogue showing one way that this can be done.

ASSESSING C

▪▪ I felt criticised

Windy: How did you feel when Kevin said that to you? Karen: I felt rejected. Windy: Actually, Karen, rejection isn’t a feeling. It is something that actually happened to you or something that you thought happened to you. Are you saying that you thought Kevin had rejected you? Karen: Yes. Windy: OK. Now, let’s assume for the moment that Kevin did reject you: how did you feel about that rejection? Karen: When I thought that he had rejected me, I felt hurt.

Here it is important to note two things. First, I explained to Karen that rejection is not a C; rather, it is an actual or inferred adversity at A. Second, I said to Karen: ‘. . . let’s assume for the moment that Kevin did reject you’. This is a typical REBT strategy. At this point, I did not challenge the validity of Karen’s inference – that is, that Kevin had rejected her. Rather, I encouraged her to assume temporarily that her inference was true so that in this case I could ascertain how she felt about this presumed rejection. REBT therapists tend to question the validity of their clients’ inferences after they have helped their clients to identify, examine and change their rigid and extreme attitudes. REBT therapists argue that their clients are in a more objective (and therefore better) frame of mind to review the validity of their inferences once they are relatively free from the biasing effects of their rigid and extreme attitudes.

XX When your client’s C is an extended statement It is rare for your clients to have had any systematic psychological education. Consequently, they will usually be quite unclear about the nature of emotions, how to discriminate among different emotions and what mainly determines their feelings. I have already commented that your clients are likely to give you vague feeling statements when you ask them how they feel about the adversities in their lives. Also, as I have just noted, they may easily confuse their emotions with the inferences they make about A. There is one other problem that you will encounter when you attempt to assess C that I wish to cover. This problem particularly occurs when you ask your clients questions about their emotions with the word ‘feel’ in them (e.g., ‘How did you feel when that happened?’). Thus, when you ask your client how they felt about a given situation they may provide you with an extended statement of what they thought about the event in question. This extended statement usually begins with the words ‘I felt’ followed by

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the extended thought. It may also commence with the phrase ‘I felt that’. The one thing that your client does not give you, however, is an accurate, clear account of their feelings. Here are some examples of what I mean.

Example 1: Therapist: How did you feel when your mother interrupted you like that? Client: I felt here she goes again; she never lets me finish a sentence. Example 2: Therapist: How did you feel when your boss gave you that assignment to do? Client: I felt that I would never be able to do it.

What can you do when your client gives an extended thought in reply to a question about their feelings? First, you can take the thought and find out what feeling was associated with it.

Windy: How did you feel when your boss gave you that assignment to do? Client: I felt that I would never be able to do it. Windy: And when you found yourself thinking that you would never be able to do it, what feeling did you experience in your gut? Client: I felt very scared.

The points to note from this example are as follows. ▪▪ I formed a bridge between the client’s extended thought and their feeling. I labelled their initial response as a thought without explanation and asked for the feeling associated with the newly relabelled thought. ▪▪ I added the words ‘in your gut’ to make it clearer that I was looking for a feeling, not a thought. The second thing you can do when your client gives you an extended thought instead of the feeling that you asked for is to explain what has happened. Tell your client that they have given you a thought rather than a feeling and then ask for the feeling again. When you do so, you might use the word ‘emotion’ rather than the word ‘feeling’, as for some people the word ‘emotion’ makes it clearer what you are looking for. For example:

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Client: I felt here she goes again; she never lets me finish a sentence. Windy: Actually, ‘Here she goes again; she never lets me finish a sentence’ is a thought rather than a feeling. What emotion did you experience in your gut when she interrupted you?

ASSESSING C

Windy: How did you feel when your mother interrupted you like that?

Client: Oh, I see. I felt angry.

If your client still has trouble identifying an emotion, you might try giving them a list of emotions from which they are asked to select the one closest to their experience. It is also useful to limit your client to a one-­word answer because this will curb their tendency to give you an extended answer. Dealing with clients who have an ongoing difficulty in identifying their emotions is beyond the scope of this book and, as such, you will need to take such issues to supervision. An important part of assessing C is evaluating your client’s motivation to change this UNE. I will deal with this issue in Chapter 11.

As an exercise, pay attention to the words used by people to depict emotional states. You can do this by listening to people in your everyday life, on television and on radio. Make a note of examples of (a) vague Cs, (b) feelings as extended statements and (c) As described as Cs. For each example, construct a response that would help clarify and specify the C.

In the following chapter, I turn our attention to assessing the ‘critical A’.

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Assessing A

ASSESSING A

◀ CHAPTER SEVEN  ▶

In order for you to get the most from this chapter, I advise you to reread the section on inferences in Chapter 1. I also suggest that you review Table 4.1, particularly the part of the table which links each pair of negative emotions with the relevant adversity-­related inference, as once you have identified your client’s unhealthy negative emotion (UNE), you will know what type of inference is associated with it. Your major task at this point is to identify your client’s A, which you will recall is that part of the ­situation which triggers your client’s rigid and extreme attitude, which is at the core of their UNE. This A can be an actual event, but more often than not it is an inference (which, as you know, may or may not be accurate). Accurately assessing the A is a complex skill, and since I do not want to confuse you or overload you with too many techniques of assessing As, I will only discuss two ways of so doing (see chapter 7 of Neenan & Dryden, 1999 for additional methods of assessing A). As I do so, I want you to bear in mind one important point. Do not question your client’s inferences. Assume that they are true until you have completed the assessment and attitude-­examination processes. There are, of course, one or two exceptions to this general rule, but at this point in your training it is a sound rule to follow. This is such an important point that it bears repetition.

While working to identify your client’s A, assume temporarily that their adversity-­related inference is correct. Do not question inferences at this point.

XX Identify the theme and its embodiment When you use this technique you first identify which theme was present in the client’s chosen specific example and then you discover which element embodied this theme. Once you have accurately done this you can drop the identified theme and continue with its embodiment, which is the A. Here is how I used this technique to identify Robert’s A. Robert felt unhealthy anger when he saw one of his colleagues, Peter, leave work early.

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Windy: When you felt anger when you saw Peter leave work early, was he breaking one of your rules? [‘Other transgresses my rule’ is one of the major themes in unhealthy and healthy anger.] Robert: Yes, I thought that Peter was showing disrespect to his colleagues by leaving early. [‘Peter showing disrespect to his colleagues’ is the embodiment of the ‘transgression’ theme.] Windy: So what you were most angry about with respect to Peter leaving was that this meant that he was breaking your rule by showing disrespect to his colleagues. Is that right? [Here I summarise by linking the identified theme – ‘other breaking rule’ – with its embodiment – ‘by leaving early, Peter showed disrespect to his colleagues’.] Robert: Exactly. [As my assessment is correct I will drop the identified theme – ‘other breaking your rule’ – from my language from now on and just refer to its embodiment – ‘by leaving early, Peter showed disrespect to his colleagues’.]

Review the emotions listed in Table 4.1. Commit to memory the inferential themes associated with each emotional pairing. Doing so will assist you greatly when assessing your client’s As via the theme and its embodiment method. You may find it useful to create an ‘aide memoire’ to which you can easily refer during therapy sessions until you know the inferential themes by heart.

XX The ‘magic question’ When you use the ‘magic question’ technique to identify your client’s A, take the following steps: Step 1. Ask your client to focus on the situation in which they disturbed themselves (i.e., where they experienced their predominant UNE).

Henry focused on the following situation in which he felt ‘hurt’: My friend Sophie was talking more to Jack than to me.

Step 2. Ask your client first to imagine that the situation cannot be changed. Then ask them to identify the one factor that would get rid of or significantly reduce their UNE in the situation.

Henry identified the following factor which would have reduced his feelings of hurt: Knowing that Sophie likes me more than Jack.

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Henry’s A was: Sophie likes Jack more than me.

ASSESSING A

Step 3. The opposite is probably the client’s A.

When using the magic question technique do not allow your client to change the actual situation at step 2. Doing so will not help you to identify the A. Emphasise to your client that the situation at A has happened, is happening or will happen. For example, Henry at step 2 may have said: ‘If Sophie had talked to me more than to Jack.’ You may need to stress that the details of the situation should stay the same. Thus:

Windy: But Sophie did in fact talk to Jack more. Given that is the case, can you decide on one factor that would stop you from feeling hurt about Sophie talking to Jack more than to you? Henry: If I knew for sure that Sophie likes me more than Jack.

In order to develop competence in these two methods, record their use in peer counselling and play the recording to your trainer for feedback. As you become more skilled in their use you may be able to use them conjointly, one as a validity check for the other. Since identifying your client’s A is a difficult skill to learn, you will probably only learn to do so with competence by playing relevant portions of your recordings with clients to your supervisor for feedback. My advice at this point of your career is don’t be obsessive-­compulsive about identifying your client’s A. Settling for an A which is ‘good enough’ but not completely on point is better than delaying the process of assessment until you get the A exactly right. If you do the latter, you may waste valuable therapy time and antagonise your client at the same time, thus placing strain on the working alliance between the two of you. In the practice of REBT, as elsewhere in life, it is important to adopt a non-­perfectionist attitude.

You have now assessed your client’s UNE at C and their adversity at A. You are now ready to identify the rigid and extreme attitudes at B that mediate between A and C.

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Assessing B

ASSESSING B

◀ CHAPTER EIGHT  ▶

You have now identified your client’s major unhealthy negative emotion (UNE) and have discovered their A. You are now in a position to assess both their rigid and extreme attitudes and their alternative flexible and non-­extreme attitudes at B. I recommend that you identify both sets of attitudes since it is time efficient. If you have taught your client the ABCs of REBT (as discussed in Chapter 3) you will have taught them the role that rigid attitudes play in emotional problems and the role that flexible attitudes play in helping people to respond healthily to adversities. In the money model you will also have alluded to the role that awfulising attitudes play in their problems and the role that non-­awfulising attitudes play in the solution to these problems. If you have not previously gone over the ABCs with your client, now would be a good time to do so, and I refer you back to Chapter 3 for how to do this. If you have already gone over this material, you will still need to review it at this point. Where appropriate, you will also need to expand your teaching to cover awfulising and non-­awfulising attitudes in more detail and to introduce attitudes of unbearability and bearability and devaluation and unconditional acceptance attitudes.

XX The two-­step approach to assessing attitudes In what I call the two-­step approach to assessing attitudes, you first outline or review the ABC assessment framework for understanding both disturbed and healthy responses to the same adversity (Step 1) and then you apply this to assessing the actual rigid/extreme attitudes that account for the client’s nominated problem and to assessing the potential alternative flexible/non-­extreme attitudes that would account for the healthy solution to this problem. Let me demonstrate how to do this, with Sue, who was anxious about the prospect of the audience laughing at her when she gave a talk. You will note that I will use a general scenario that is not relevant to Sue’s nominated problem. I do this because I want Sue to focus on the model without becoming emotionally upset, which will interfere with her processing.

Windy: So to sum up, Sue, you were anxious about the prospect of the audience laughing at you. Sue: Right. Windy: Now your anxiety is what in REBT we call C, your emotional consequence. So let me write this up on this whiteboard under C. Next, the prospect of the audience laughing at you is that part

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of the situation that you were particularly anxious about. This is what we call A, so I’ll write this up on the whiteboard under A. ▪▪ A = Prospect of audience laughing at me ▪▪ B = To be determined ▪▪ C = Anxiety Now, do you remember when I taught you the ABCs of REBT what B stands for? Sue: My attitudes. Windy: Correct. As you see from the whiteboard we do not yet know what your attitude is towards the audience laughing at you that led to your anxiety. This is what we need to do now. OK? Sue: OK. Windy: Now, do you recall from the money model what type of attitude underpins people’s emotional problems? Sue: Their rigid attitudes. Windy: That’s right. And what were the healthy alternatives to these rigid attitudes? Sue: Flexible attitudes. Windy: Let me write these down under two main headings. Flexible attitudes are the main type of  flexible and non-­ extreme attitudes, so I’ll write that down under the heading ‘flexible/ non-extreme attitudes’, and rigid attitudes are the main type of rigid/extreme attitudes. Flexible/non-­extreme attitudes Flexible attitudes

Rigid/extreme attitudes Rigid attitudes

Any questions so far? Sue: No, that’s quite clear. You’ve just summed up what you showed me earlier. Windy: Right. What I want to do now is to show you the three non-­extreme attitudes that stem from your flexible attitudes and the three extreme attitudes that stem from your rigid attitudes. Then we can apply this to determine which set of attitudes you were holding when you became anxious about being laughed at. OK? Sue: Fine. Windy: Now, if you hold a flexible attitude towards an adversity, you want something, but you do not insist that you must have it. If you believe that, then if you do not get what you want are you likely to believe (a) ‘it’s bad that I haven’t got what I want, but it’s not terrible’ or (b) ‘it’s awful that I do not have it’? Sue: I’d believe that it’s unfortunate.

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Sue: I’d believe that it would be awful.

ASSESSING B

Windy: Right. Now, if you hold that you absolutely have to have the object in question, which of those attitudes that I have outlined will you hold?

Windy: Right. Let me put that up on the board Flexible/non-­extreme attitudes Flexible attitudes

Rigid/extreme attitudes Rigid attitudes

Non-­awfulising attitudes (‘It’s bad that. . .’)

Awfulising attitudes (‘It’s awful that. . .’)

[I have drawn a line from flexible attitudes to non-­awfulising attitudes and a line from rigid ­attitudes to awfulising attitudes to emphasise for the client that in both cases the latter is derived from the former. Not all REBT therapists hold that rigid attitudes and flexible attitudes are primary and that awfulising attitudes and non-­awfulising attitudes and the other extreme and ­non-­extreme attitudes that I will describe presently are derived from these primary attitudes. Such REBT therapists would therefore omit the connecting lines.] Windy: Any questions on awfulising attitudes? Sue: Well, is that different from when I say, ‘It’s awful weather’? Windy: When you are disturbed, ‘awful’ means that it is worse than 100% bad and it must not be as bad as it is. Whereas when you say that it is awful weather you really mean that it is bad weather and you aren’t usually emotionally disturbed about it. Does that answer your question? Sue: Yes, that’s clear. Windy: Any questions on non-­awfulising attitudes? Sue: No, that’s fine. Windy: Now on to the next set of attitudes. When you hold a flexible attitude towards an adversity, again you want something, but you do not insist that you must have it. If you hold this attitude then if you do not get what you want are you likely to believe (a) ‘it’s a struggle for me to bear this situation, but I can bear it’ or (b) ‘it’s unbearable that I do not have it’? Sue: I’d believe that it is bearable but a struggle to bear it. Windy: Right. Now, if you hold a rigid attitude that you absolutely must have the object in question, which of those two attitudes that I have outlined will you hold? Sue: I’d believe that it would be unbearable. Windy: That’s right. Let me add that to the board.

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Flexible/non-­extreme attitudes Flexible attitudes

Rigid/extreme attitudes Rigid attitudes

Non-­awfulising attitudes (‘It’s bad that. . .’) Attitudes of bearability (‘I can bear it. . .’)

Awfulising attitudes (‘It’s awful that. . .’) Attitudes of unbearability (‘I cannot bear it. . .’)

Any questions, Sue? Sue: No, that’s perfectly clear. Windy: And do you go along with it or not? Sue: It makes very good sense and I can already see how it applies to me. Windy: I’m pleased about that; but I’ve got one other concept to go over before we see how it all applies to you. OK? Sue: OK. Windy: When you hold a flexible attitude towards an adversity, again you want something, but you do not insist that you must have it. If you hold this attitude, then if you do not get what you want and you think that this is down to you, are you likely to hold the attitude (a) that you are a fallible human being for having failed or (b) that you are a thoroughgoing failure for having failed? Sue: I’d believe that I was fallible. Windy: But what if you hold the rigid attitude that you absolutely have to do well in the test and you do not, which of those two attitudes towards yourself would you tend to hold? Sue: I see what you are getting at. I’d think that I was a failure. Windy: This concept also applies to how you view other people, but we will get to that when it becomes relevant. Any questions or comments or should I put this concept up on the board? Sue: Put it up on the board.

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Flexible attitudes

Rigid attitudes

Non-­awfulising attitudes (‘It’s bad that. . .’)

Awfulising attitudes (‘It’s awful that. . .’)

Attitudes of bearability (‘I can bear it. . .’)

Attitudes of unbearability (‘I cannot bear it. . .’)

Devaluation attitudes (self/others/life) (‘I’m a fallible human being. . .’)

Unconditional attitudes (self/others/life) (‘I’m a failure. . .’)

ASSESSING B

Now, let me give you a handout which is basically the same as what I’ve written on the board, which you can use for future reference. Sue, I’ve gone over the heart of the model that I use to help people to understand their emotional problems. Before we apply it to the problem that we have been focusing on, do you have any final questions or observations to make? Sue: No. It seems to be a good model. Windy: Any doubts or reservations? Sue: Only about applying it. Windy: Well, we’ll come to that in due course. Now let us apply the model and see if we can determine the attitudes that underpinned your anxiety about being laughed at by the audience. Let us focus on that. OK? Sue: OK. Windy: Here is the ABC framework that we will use: ▪▪ A = Prospect of audience laughing at me ▪▪ B = To be determined ▪▪ C = Anxiety [At this point I am going to use the four rigid/extreme attitudes and their flexible/non-­extreme attitudes that I have discussed with Sue as a guide to the assessment questions I am about to ask. My questions will therefore be theory-­driven.] Windy: Now, what do you think your rigid attitude was towards being laughed at? Sue: The audience must not laugh at me. Windy: And the flexible attitude you could have? Sue: I do not want them to laugh at me, but it does not have to be the way I want. Windy: Did you have an awfulising attitude towards being laughed at? Sue: It would be terrible if they laughed at me. Windy: And the non-­awfulising attitude you could have? Sue: It would be bad if they laughed at me but not terrible. Windy: Did you have an attitude of unbearability? Sue: [looking up at the whiteboard] That’s the ‘I cannot bear it’ attitude, isn’t it? Windy: Yes. Sue: I would not be able to bear it if they laughed at me. Windy: And the attitude of bearability you could have? Sue: It would be difficult for me to bear it if they laughed at me, but I could bear it. Windy: Finally, were you devaluing yourself, the audience or the situation in this episode?

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Sue: I was devaluing myself. Windy: What did it sound like? Sue: If they laugh at me it would prove that I am incompetent. Windy: As a speaker or as a person? Sue: Both. Windy: And the attitude of acceptance you could have? Sue: If they laugh at me, it would not prove that I am incompetent. It would prove that I am a fallible human being who may have said something stupid. Windy: So, let us complete the ABC on this problem that we started earlier with both sets of attitudes. . . [writing on the board] A = Prospect of audience laughing at me B = rigid/extreme attitudes Rigid attitude = The audience must not laugh at me

B = flexible/non-­extreme attitudes Flexible attitude = I do not want the audience to laugh at me, but it does not have to be the way I want

Awfulising attitude = It would be terrible if the audience laughed at me

Non-­awfulising attitude = It would be bad if the audience laughed at me but not terrible

Attitude of unbearability = I would not be able to bear it if the audience laughed at me

Attitude of bearability = It would be difficult for me to bear it if the audience laughed at me, but I could bear it

Devaluation attitude = If the audience laughs at me it would prove that I am incompetent

Unconditional acceptance attitude = If the audience laughs at me, it would not prove that I am incompetent. It would prove that I am a fallible human being who may have said something stupid

C = Consequences

C = Consequences

Emotional consequences = Anxiety

Emotional consequences = ?

Now, Sue, is this an accurate assessment of your anxiety about being laughed at? Sue: Very accurate. Windy: Now, let us look at the right-­hand column of the board. If you have a strong conviction in the flexible/non-­extreme attitudes listed there, how would you feel about the prospect of the audience laughing at you? Sue: I still would not like it, but I would not be anxious.

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Sue: I’m not sure. Windy: Would the feeling ‘unanxious concern’ capture it?

ASSESSING B

Windy: What would you call that feeling?

Sue: Perfectly. Windy: Let me change the ‘?’ to ‘unanxious concern’.

You will note that I assessed Sue’s potential flexible and non-­extreme attitudes as well as her actual rigid and extreme attitudes. I do this so that when I help the client to examine their attitude, they can examine both sets. Comparing both sets of attitudes, in my view, facilitates the attitude-­examination process. However, this is a personal view and other REBT therapists do not necessarily assess B as I do. The above is a theory-­driven way of assessing your client’s attitudes. To review, it involves two basic steps. In the first step, you teach your client the role of rigid/extreme and flexible/non-­extreme attitudes in disturbed and healthy responses to adversity respectively, and you do so in general terms, dealing with any doubts, reservations and misunderstandings they may have along the way. In the second step, you apply this framework to the client’s nominated problem. For a different, less theory-­driven way of assessing clients’ attitudes see Dryden and Neenan (2004). I prefer the theory-­driven method of assessing attitudes because it has an educational as well as a therapeutic purpose. Here, you actively teach your client which rigid/extreme attitudes to look for in both the client’s nominated problem and in the other emotional problems they may wish to cover during therapy. As such, it tends to save therapeutic time and encourages the client to take responsibility for assessing their own problems. It also clearly provides the client with the alternative set of flexible/non-­extreme attitudes that they can aim to develop as they work towards developing healthy solutions to their emotional problems.

XX Windy’s review assessment procedure (WRAP) The approach to assessing attitudes that I have presented above has two steps: a general educational step and a specific one that is focused on the client’s nominated problem. The WRAP method is used when the therapist and client just want to assess the client’s nominated problem. I will use the example of Sue to show you how to use this method of assessing attitudes. As such, I will talk to Sue directly.

1. At this point, we know what your emotion is at C (‘anxiety’) and we know what your adversity at A is (‘the audience may laugh at me’). 2. We also know what your preference is (‘I do not want the audience to laugh at me’). [I know this because I am using REBT theory to guide my work. This states that whenever a client has an emotional problem this is based on a preference that they have either for something to happen or for something not to happen (as in Sue’s case).]

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3. What we do not know yet is which of two attitudes your C (‘anxiety’) is based on  – a rigid attitude or a flexible attitude1. So is your C (‘anxiety’) based on Attitude #1, ‘I do not want the audience to laugh at me and therefore they must not do so,’ or on Attitude #2, ‘I do not want the audience to laugh at me, but it does not have to be the way I want’? [If Sue does not see that her C (‘anxiety’) is based on Attitude #1, I would discuss this with her until she understands this rigid attitude–UNE connection.] 4. Now answer the following question: ‘If you had strong conviction in Attitude #2, how would you feel about A (‘the audience laughing at you’)?’ [If Sue does not say ‘concern’ or some suitable synonym, I would discuss this with her until she understands this flexible attitude–healthy negative emotion (HNE) connection.] 5. You now see clearly that your UNE at C (‘anxiety’) is based on your rigid attitude (‘I do not want the audience to laugh at me and therefore they must not do so’) and that the HNE alternative (‘concern’) is based on your flexible attitude (‘I do not want the audience to laugh at me, but it does not have to be the way I want’). 6. Does it make sense for you to set the concern as your emotional goal in this situation and see that developing conviction in your flexible attitude (‘I do not want the audience to laugh at me, but it does not have to be the way I want’) is the best way of achieving this goal? [If Sue has any doubts, reservations or objections to doing so, I would discuss them with her.]

In the next chapter, I deal with the important issue of assessing for the presence of your clients’ e­ motional problems about their emotional problems, or what are known in REBT as meta-­emotional problems.

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  The WRAP technique can also be used to identify extreme attitudes and their alternative non-­extreme attitudes.

Assessing meta-­emotional problems Your clients will frequently make themselves emotionally disturbed about their emotional problems, thus unwittingly giving themselves a ‘double dose’ or ‘two problems for the price of one’. I call these ­secondary emotional problems ‘meta-­emotional problems’, a term which literally means emotional problems about emotional problems (Dryden,  2021a). Like primary emotional problems, meta-­emotional problems are characterised by unhealthy negative emotions. There are two major issues that arise in REBT which pertain to meta-­emotional problems. The first concerns assessment and the second relates to which emotional problem you and your client target for change first: your client’s primary emotional problem or their meta-­emotional problem. I will deal with both these issues in this chapter. Before showing you how to assess your clients’ meta-­emotional problems, let me first deal with a training issue. Some REBT therapists routinely determine whether or not their clients have meta-­ emotional problems, whereas others will enquire about their existence only when their clinical intuition leads them to suspect that meta-­emotional problems may be present. At this stage of your career as an REBT therapist, you probably lack such intuition, so it might be advantageous for you to ask your clients routinely how they feel about their primary emotional problems. The drawback to doing this is that you may become confused. Many trainees find the REBT assessment process difficult enough when dealing with their clients’ primary emotional problems. Introducing meta-­emotional problems into the picture at a time when they are struggling with primary problems would prove too much for these trainees at this juncture. While I will show you how to assess meta-­emotional problems, I urge you to consider carefully your own skill and confidence level as an REBT practitioner when deciding whether or not you are going to deal with your clients’ meta-­emotional problems. Discuss this issue with your REBT trainer or supervisor. There is no definite point in the assessment process at which it is best to determine whether or not your client has a meta-­emotional problem. You can do so (a) as soon as your client has mentioned that they have a primary emotional problem; (b) after you have assessed their primary problem; or (c) after you have helped them to examine both sets of attitudes that underpin their primary problem and potential solution and they have started to effect some change to the problem. Another way of determining whether your client has a meta-­emotional problem is by investigating reasons why they are not ­making expected progress on their primary problem. One reason for this may be that they have a meta-­emotional problem which is getting in the way of the work that they otherwise would be doing on the primary problem.

A s s e s s i n g m e t a - ­e m o t i o n a l p r o b l e m s

◀   C H A PTER NINE  ▶

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XX The ABCs of meta-­emotional problems You carry out an assessment of your client’s meta-­emotional problem in the same way as you do their primary emotional problem. Here is an illustrative example.

Larry is anxious about giving presentations at work. I assessed the ABC of his primary1 problem as follows: A = I won’t get promotion if I don’t give an excellent presentation B = (i) I must get promoted

(ii) It would be awful not to get promoted

(iii) Not being promoted means that I’m totally incompetent C = Anxiety I then explored the possible presence of a meta-­emotional problem as follows: Windy: Now, Larry, some people have what I call secondary emotional problems about their primary problems. . . [I usually refrain from using the term ‘meta-­emotional problems’ with clients as it can come over as psychological jargon.] . . . What I mean by this is that if someone is angry, for example, then they may feel guilty about experiencing angry feelings. The anger is their primary problem and the guilt they feel about their anger is their secondary problem. Am I putting that clearly? Larry: Yes, no person has two problems: anger and the guilt they feel about their anger. Windy: Right. Now let’s see if you have a secondary problem about your primary anxiety. OK? Larry: Yes. Windy: Now, when you are anxious about the prospect of not getting promotion, how do you feel about being anxious? Larry: I’m ashamed of myself. Windy: And what’s the most shaming aspect about being anxious in that situation? [Note that I am not assuming that Larry’s feelings of anxiety are his A. As a result of my assessment, it seems that ‘not coping’ is his A.] Larry: Being anxious means I am not coping. Windy: So, you are most ashamed about having anxious feelings in this situation. Let’s see if we can figure out what attitudes you hold towards not coping that are leading to secondary feelings of shame. We can use the sheet of rigid/extreme and flexible/non-­extreme attitudes I’ve given you.

I have omitted the assessment of Larry’s flexible and non-­extreme attitudes so that you can focus on the main point of this ­chapter, which is the assessment of meta-emotional problems.

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A = Not coping with the prospect of not being promoted B = Rigid/extreme attitudes (actual) ▪▪ I must cope with the possibility of not being promoted ▪▪ It is terrible not to cope ▪▪ Not coping means that I am a weak person

B = Flexible/non-­extreme attitudes (potential) ▪▪ I would like to cope with the possibility of not being promoted but I don’t have to do so ▪▪ It is bad not to cope but hardly terrible ▪▪ I am not a weak person if I don’t cope. I am an ordinary human being with strengths and weaknesses

C = Shame

C = Disappointment

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The ABC of Larry’s meta-­emotional problem turned out thus:

It is often helpful to your client to put both their primary emotional problem and their meta-­emotional problem on the whiteboard so that they can see them clearly in diagrammatic form. Otherwise, your client might get lost in a welter of words. Figure 9.1 shows a diagrammatic form of Larry’s two problems.

XX When the meta-­emotional problem is the major focus When you have ascertained that your client has a meta-­emotional problem, you are faced with a choice: (a) do you start to work on their primary emotional problem (or continue to work on this nominated problem if you have already started to work on it) or (b) do you start to work on their meta-­emotional problem (or switch to this problem if you have started work on their primary problem)? First, let me reiterate what I said earlier. If you are unsure of your REBT skills and consider that working in therapy at both the level of your client’s primary emotional problem and their meta-­emotional problem is too daunting or confusing for you at this stage of your career as an REBT therapist, then just work at the level of your client’s primary emotional problem.

If you want to develop your skills at working with your clients’ primary and meta-­emotional problems then practise doing so in peer counselling. Pair up with a trainee colleague (with another trainee as observer) and have your ‘client’ choose a primary personal problem about which they have a meta-­emotional problem. Assess both problems and choose with the ‘client’ which problem to start with; this then becomes the nominated problem. Record the interview and stop the recording when you become confused or lose your way. Review the recording at the place where you began to have difficulties and with the help of the observer and your ‘client’ get back on track. Do this whenever you become stuck until you can deal with primary and meta-­emotional problems with confidence. This process should help you to develop competence at working productively at the level of primary and meta-­emotional problems with your real clients.

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Figure 9.1  A diagrammatic representation of Larry’s primary and meta-­emotional problems and their potential solution. 98

1. When the presence of the meta-­emotional problem interferes with the work that you are trying to do on your client’s primary emotional problem in the session.

For example, if while working with Larry on his unhealthy anxiety problem, I noticed that he seemed quite distracted, I would ask him what he was focusing on during our work. If Larry replied that he was riddled with shame over the weakness he exposed through his anxiety, I would encourage him to deal with his shame first, then I would strive to help him feel disappointed about being anxious (rather than ashamed about it). After his shame was resolved and Larry felt healthily disappointed about his feelings of anxiety he could give his full attention while in session to working on overcoming his primary anxiety (about the possibility of missing a promotion).

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Having made these points, here are four criteria for dealing with your client’s meta-­emotional problem before their primary emotional problem.

2. When the presence of the meta-­emotional problem interferes with the work that the client is trying to do on their primary emotional problem outside the session.

For example, Larry may attempt to identify and examine the rigid and extreme attitudes that underpin his anxiety about missing a promotion at work. However, he may fail to do so and be puzzled as to the reason why. In the next therapy session, it may become clear that Larry’s feelings of shame about his not coping with the primary problem (which are based on the rigid and extreme attitudes that he must cope with the primary problem and that he is a weak person for not doing so) are distracting him from confronting his primary anxiety problem between ­sessions. Larry is more able to carry out the work he needs to do between therapy sessions in order to overcome his anxiety once he conquers his secondary emotional shame problem.

3. When the meta-­emotional problem is clinically more important than the primary emotional problem. There are certain client problems where the meta-­emotional problem is clinically more important than the primary emotional problem. You will get to know these as you become clinically more experienced. However, two common client problems where the meta-­emotional problem is more crucial are (a) generalised anxiety where your client’s anxiety about anxiety is more of a feature than the primary anxiety and (b) certain mild obsessive thought problems where your client’s secondary intolerance of the original disturbing thought is the most salient feature of the problem. 4. When your client sees the sense of addressing their meta-­emotional problem before their primary emotional problem. While I have put this last, it is perhaps the most important. Even though the preceding three criteria for addressing your client’s meta-­emotional problem before their primary problem are sound, if your client does not see the sense in doing so, then proceeding with their meta-­emotional problem will

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threaten the therapeutic alliance that you have developed with your client. Thus, it is useful to present your client with a plausible rationale for starting with their meta-­emotional problem. Only begin this work when they see the sense of so doing.

On this point, a good training exercise is for you to practise presenting such rationales in peer counselling to your fellow trainee ‘client’. Record your rationales under each of the three conditions listed below: 1. When your ‘client’ is distracted by their meta-­emotional problem when you are attempting to work on their primary emotional problem in the session. 2. When your ‘client’ is distracted by their meta-­emotional problem when attempting to work on their primary problem outside the session. 3. When the meta-­emotional problem is more clinically significant than their primary emotional problem. Play your recordings to your REBT trainer or supervisor and get feedback on your performance.

In the next chapter, I will focus on goal-­setting with your clients.

Goal-­setting

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◀   C H A P TE R TEN  ▶

It is easy sometimes to lose sight of the fact that the purpose of therapy is to help your clients achieve their goals. However, it should also not be forgotten that as a therapist you have goals in therapy as well. Thus, in a seminal book entitled The Goals of Psychotherapy, Mahrer (1967), the book’s editor, concluded from his review of the contributions to the book that therapists have two major types of goals: (a) those concerned with the reduction of psychological disturbance and (b) those concerned with the promotion of psychological health. As a therapist, the more you can encourage your client to be explicit about their goals and the more you can be explicit about your own goals, the better. Doing so will enable the two of you to work cooperatively towards agreed goals. Such cooperative striving towards the achievement of agreed goals is, as Bordin (1979) has argued, an important hallmark of effective therapy. As I have already argued, REBT is an approach to psychotherapy that stresses the importance of explicit, open communication between you and your client. It also recommends that you set goals with your client. Thus, this therapeutic system encourages you to engage in the very activities that will help promote effective therapeutic change. I have already touched on the issue of goals in some of the previous chapters (namely, Chapters 4, 6 and 8). In this chapter, goals will be the major focus of my discussion. I will deal with goals at three levels. First, I will consider goals in relation to dealing with specific examples of your client’s ­problems. Then, I will consider goals in relation to your client’s problems as these are broadly conceptualised. Third, I will consider the issue of goals as they relate to the distinction between reducing ­disturbance and promoting growth.

XX Setting a goal with respect to a specific example of your client’s nominated problem Let me outline the steps for effective goal-­setting in REBT as these relate to specific examples of your client’s nominated problem. As you will see, this is not the simple process it may appear at first sight. Steps for effective goal-­setting While your client may well have more than one problem, I will deal with the situation where you are working with a given client problem. I want to stress one point at the outset. While I will outline a suggested sequence with respect to the steps you need to take to elicit your client’s goals for change, it is important for you to note that you may well set goals at different times in the therapeutic process. For example, I make an important distinction between your client’s defined problem and their assessed problem. The defined problem is the way your client sees or defines their focal concern, whereas the

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assessed problem is the same problem put into an ABC format. I argue below that it is important to elicit goals for both the defined problem and the assessed problem, and you may do this at different times in the REBT therapeutic process. The work you are likely to do on your client’s goal as this relates to the assessed problem will occur later, and sometimes much later than the work you will do eliciting their goal as this relates to the defined problem. Remember this as we cover the following steps. Step  1: Ask for  a specif ic example of  your client’s nominated problem  The first step in the goal-­ setting process is to encourage your client to give you a specific example of their more general problem. As I discussed in Chapter 5, you can best assess your client’s nominated problem if they provide you with a specific example of it, because this will help you to identify a specific A, a specific unhealthy negative emotion (UNE) and specific rigid/extreme attitudes. Step 2: Communicate your understanding of the problem from the client’s point of view and come to an agreement with them on this def ined problem  The second step is for you to understand how your client sees the problem and to communicate this understanding to the client. This is important for two reasons. First, it helps your client to ‘feel’ understood. Second, knowing how your client sees the problem will help you to assess it using the ABC framework. It is at this point that your basic counselling skills come into play. As you need to convey understanding, I particularly recommend using the skills of clarification and reflection. In addition, you will need to phrase your attempts at understanding as just that – attempts. As such, there needs to be a tentative quality to your interventions, which you need to put as hunches to be confirmed or denied, rather than as incontrovertible facts. For example, it is best for you to say: ‘So, you seemed to find it difficult getting down to studying when you knew that your friends were out having a good time. Have I understood you correctly?’, rather than: ‘You found it difficult getting down to studying when you knew that your friends were out having a good time.’ In the former statement, you phrase the statement in a tentative fashion and put your understanding as a hunch, which you are testing. This enables your client to correct you if you are off track. If you make the latter statement, however, you phrase the statement more definitely and do not check out your understanding of what your client has said. Rather, you proceed on the basis that you are right! This makes it more difficult for your client to correct you if you are off beam. The purpose of being tentative and testing out your hunches is that it helps you to come to an agreed understanding with your client on the problem as they see it. I call this ‘coming to an agreement with the client on the defined problem’. Later in the goal-­setting process, you will need to arrive at an agreement with the client on the assessed problem. Step 3: Elicit your client’s goal with respect to the def ined problem  It is important to elicit your client’s goal in relation to the defined problem. While this goal may change once you have assessed the problem, it is helpful, nonetheless, to learn what your client considers a satisfactory solution to their problem. Indeed, it is here that you will frequently discover that your client has unrealistic or unobtainable goals for change. If so, you will need to address this issue. Whether you do so at the point when your client reveals their unrealistic or unobtainable goal or whether you choose to do so later, you do have to deal with the issue; otherwise, your client will think that you agree with their goal when, in fact, you don’t. I will discuss how to deal with unrealistic and unobtainable goals in a moment, but first let me show you how you might usefully elicit your client’s goal with respect to the defined problem. Let me use the example that I introduced above. As a reminder, the client (whose name is Clare) defined her problem with respect to a recent specific example as follows: ‘I found it difficult getting down to studying when I knew that my friends were out having a good time.’ Here is how I would work with Clare to identify her goal as it relates to this defined problem.

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[Alternative questions might include: a.  What would you like to be able to do instead?

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Windy: So you found it difficult getting down to studying when you knew your friends were out having a good time. What would you like to achieve from counselling on this issue?

b.  How would you like to change? c.  What would be in your best interests to do?] Clare: To be able to study even when I know my friends are out enjoying themselves. If Clare replied that she didn’t know, I would have employed other techniques such as: ▪▪ Imagery: This involves asking Clare to imagine a preferred solution to her problem (e.g., ‘Close your eyes and imagine a scene where you are doing what is productive for you even when your friends are out enjoying themselves. What would you be doing in that image?’). Having elicited this preferred scenario, I would ask Clare to give reasons for her choice. ▪▪ Time projection: This involves Clare projecting herself into the future and stating how she would like to have acted at the time in question (e.g., ‘Imagine that we are a year in the future. Looking back would you rather have studied at the time we are discussing or not?’). Then, I would again ask her to give reasons for her answer. ▪▪ A best friend’s suggestion: This involves asking Clare to imagine how her best friend would suggest she handle the problem (e.g., ‘Would your best friend suggest that you study even though you know that they and others might be out enjoying themselves? If so, why do think they would say that?’). If you use this technique you need to ensure that your client’s best friend does, in fact, have her interests at heart. ▪▪ A worst enemy’s suggestion: This is the opposite of the best friend’s suggestion and is useful in that it would help Clare to see that an enemy might be quite happy to see her continue this self-­ defeating behaviour (e.g., ‘What would your worst enemy suggest that you do when you know that your friends are out enjoying themselves and you need to study?’). I would again explore Clare’s answer and ask her to set a suitable goal at the end of the exploration. ▪▪ Therapist-­suggested options: If none of the above techniques helped to elicit Clare’s goals on her defined problem, then as her therapist I might provide her with possible goal options. In doing so, I would give her an opportunity to discuss these options with me. [My role here is to encourage her to reflect on the advantages and disadvantages of all the p ­ rovided options as a way of choosing a relevant goal.]

Step 4: Deal with unrealistic and unobtainable goals  It sometimes transpires when you are working with your client to identify their goals with respect to their defined problem that they will nominate goals that are unrealistic or unobtainable. As I pointed out earlier, when your client comes up with such a goal you do need to deal with it, but not necessarily at the precise time when your client discloses it. Thus, while making a mental or preferably a written note of this goal, you may choose to wait to deal with it until you have assessed your client’s problem and determined their goal with regard to the

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assessed problem. When you decide to confront your client on their unrealistic or unobtainable goal is a matter of clinical judgement, and I urge you to discuss such matters with your REBT supervisor. What I will do here is to detail the kinds of client goals that are unrealistic or unobtainable. I will give an example of how to deal with the situation where your client nominates an unrealistic or unobtainable goal in relation to their defined problem. What are unrealistic and unobtainable goals?  It would be nice if your clients set goals for change that were achievable, realistic and involved them changing some aspect of themselves. Suffice it to say, this does not always occur! The following list contains the unrealistic or unobtainable goals that you will most frequently encounter in REBT. 1. Changing impersonal negative events. Here, your client nominates a goal which involves a change in some aspect of the situation about which they are disturbing themselves (in other words, A).

Let’s suppose King Canute came to see you for counselling. His complaint is that he is unhealthily angry because the tide will not obey him and go back when he orders it to do so. You have accurately defined his problem and go on to ask him for his goal. He replies that he wants you to help him to change the tide so that it goes back at his command. Would you accept this as a legitimate therapeutic goal? Of course you wouldn’t. You would explain to King Canute that influencing the tide is outside his control despite the fact that he is a king. You would encourage him instead to set an achievable goal, feeling healthily angry rather than unhealthily angry about the grim reality that the tide is not compliant with his wishes.

2. Changing other people. Some of your clients come to counselling convinced that their emotional problems are caused by the way other people treat them. They adhere to what we have called an A → C viewpoint. As such, when you ask them for their goals, they say that they want to change these people. This is not an obtainable goal since others’ behaviour is outside the direct control of your clients.

One of your clients, Jill, is depressed because she claims that her boss made, from her perspective, an unreasonable demand on her at work. In response to your enquiry concerning her goal for change, she replies: ‘I want my boss to stop making unreasonable demands on me.’ If you consider this goal carefully, it points to a change in the other person’s behaviour. Now, on the face of it, this may seem quite reasonable. If Jill’s boss is making too many demands on your client, what is wrong in Jill wanting him to change? The answer is both nothing and everything. There is nothing wrong with her goal if we treat it as a healthy desire for her boss to change. However, there is everything wrong with this statement as a therapeutic goal. It is important for you to note and to encourage your client to appreciate that it is not within her power to change her boss. Jill can only realistically hope to change what is in her power to change – namely, her thoughts, behaviour, feelings, etc. Thus, as she cannot directly change her boss, you cannot, as her therapist, profitably accept this as a legitimate goal. Now, of course, Jill can influence her boss to change, and these influence attempts may be successful. This means that it is legitimate to accept as Jill’s goal changes in her attempts to influence her boss, because these new attempts are within her control. Accepting Jill’s new influence attempts as a legitimate goal for change is very different from accepting a change in her boss’s behaviour as a legitimate goal. The former is within Jill’s control; the latter is not. 104

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3. Feeling neutral about adversities. It sometimes occurs in REBT that clients indicate that they want to feel neutral about negative events. Consider Geraldine, who was rejected by her boyfriend and felt very hurt about this. Here is an excerpt from my therapy with her that illustrates this unrealistic goal and how I responded to it. Windy: So, Geraldine, the problem as I understand it is that you feel very hurt about Keith ending the relationship. Have I understood you correctly? Geraldine: Yes, you have. Windy: What would you like to achieve from counselling on this issue? Geraldine: I want not to feel anything about it. Windy: The only way I can help you do that is to help you to develop the attitude ‘I don’t care whether Keith ended the relationship or not. It is a matter of indifference to me.’ How realistic is it for you to believe that? Geraldine: Put like that it isn’t realistic at all. But it hurts so much I just want an end to the pain. Windy: I understand that you do feel very hurt about the ending of your relationship with Keith and I do want to help you deal with your hurt. But I want to do so in a way that is realistic and lasting. The trouble with trying to convince yourself that you don’t care when, in fact, you care too much is that it is a lie and you just can’t sustain that lie. How about this as an alternative? What if I can help you to feel sorrowful about being rejected rather than very hurt about it? This would mean that you would still care about what happened to you, but you wouldn’t care too much about it. How does that seem to you as a reasonable goal? Geraldine: I see what you mean. That would be fine if I could achieve it. [If Geraldine could not see the difference between hurt and sorrow, I would use a variety of teaching points to clarify this distinction (see Chapter 4).] Windy: If you can see the sense of that then I’ll do my best to help you achieve it. 4. Seeking goals which would perpetuate the client’s rigid and extreme attitudes. Sometimes clients come up with goals with respect to their defined problems that are within their control, but pursuing these goals would serve to perpetuate their rigid and extreme attitudes. Let me give a few examples of what I mean.

Clare’s defined problem (with respect to specific example): I found it difficult getting down to studying when I knew that my friends were out having a good time. Goal: To leave my studies and join my friends whenever they go out without feeling guilty. This would not be an unrealistic goal if Clare were studying for long hours and not taking any breaks from her work. However, in this case, Clare was procrastinating over her studies and spending her time watching TV when she knew that her friends were out enjoying themselves. If I had accepted her goal of joining her friends whenever they went out I would have been helping her, unwittingly, to perpetuate the rigid and extreme attitudes that underpinned her procrastination. Instead, I first established that studying was in Clare’s best long-­term interests and then helped her to plan her time so that she spent enough time studying and some time socialising with her friends. 105

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Jill’s defined problem (with respect to specific example): I’m depressed because my boss made an unreasonable demand on me at work. Goal: To tell my boss off whenever he makes unreasonable demands on me. The problem with this goal is twofold. It does not deal with the issue of Jill’s depression and it encourages her to develop a new emotional problem – unhealthy anger. Thus, if I had accepted this goal I would have been leaving intact the rigid and extreme attitudes underpinning Jill’s depression and encouraging the development of unhealthy anger-­related rigid/extreme attitudes. This is how I proceeded. First, I encouraged Jill to consider the benefits of healthy assertion over making unhealthy anger-­based rebukes in the light of what she knows about her boss (review the material on healthy anger vs unhealthy anger in Chapter 4 as an aid here). Second, I helped Jill to see that she would need to deal with her depression before she could assert herself adequately with her boss.

Geraldine’s defined problem: I feel very hurt about Keith ending our relationship. Goal: To beg Keith to take me back. Once again this goal does not help the client to tackle her feelings of hurt about the rejection. Indeed, Geraldine is seeking to deal with the rejection by getting rid of it. In doing so, her begging behaviour indicates that she has another problem – a dire need either to have a relationship or a dire need for comfort. If I had accepted her goal I would have bypassed her hurt-­related rigid/ extreme attitudes and legitimised whatever rigid/extreme attitudes underpinned her begging. Instead, I helped Geraldine to see that sorrow was a healthier alternative to rejection than hurt, and instead of begging Keith to take her back, she planned instead to discuss his reasons for rejecting her and to learn from it if he pointed out to her things she did or failed to do that would impact negatively on her future relationships.

5. Seeking intellectual insight. REBT distinguishes between two types of insights: intellectual insight and emotional insight (Ellis, 1963). It defines intellectual insight as a light acknowledgement that your client’s rigid and extreme attitudes are inconsistent with reality, illogical and self-­defeating and that the flexible and non-­extreme alternatives to these attitudes are consistent with reality, logical and self-­ helping. However, such insight does not, by itself, change how your client feels and acts, but is seen as an important prelude to emotional insight. This form of insight is defined as a strong conviction that your client’s rigid and extreme attitudes are inconsistent with reality, illogical and self-­defeating and that the flexible and non-­extreme alternatives to these attitudes are consistent with reality, logical and self-­helping. Here, this strong conviction does affect how your client feels and acts. In short, when your client has intellectual insight, they still experience UNEs and act in self-­defeating ways when faced with adversities, whereas with emotional insight, they respond to these same adversities with healthy negative emotions (HNEs) and self-­enhancing behaviour. When your client responds to your enquiry about goals by saying that they want to understand their nominated problem, they often hold the implicit idea that gaining such insight is sufficient for

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change to occur. Unless this idea is identified and confronted, your client will only make limited gains from REBT. While some clients do seek what may be called ‘REBT intellectual insight’ in that they are genuinely interested in what the approach has to say about the nature of their problems, most clients in my experience are looking for what may be called ‘psychodynamic intellectual insight’, by which they hope to identify childhood determinants of their problems that, when discovered, will lead to problem resolution. It follows from what we have said above that neither REBT nor psychodynamic intellectual insight is sufficient for psychological change to take place. Explaining to your client that intellectual insight has its place but is insufficient for change to occur often helps them to set a more functional goal. It also helps the client to distinguish between insight as a therapeutic means and a change in psychological functioning as a therapeutic goal. This is demonstrated in the following interchange.

Windy: So you find it difficult getting down to studying when you know your friends are out having a good time. What would you like to achieve from counselling on this issue? Clare: I’d like to understand why I have this problem. Windy: What information are you looking for? Clare: Well, there must be something in my childhood that would explain why I have so much difficulty studying when my friends are out. Windy: Let’s suppose there was. What would you hope having this information would do for you? Clare: It would help me solve this problem. Windy: And if your problem was solved what would be different? Clare: I would be able to study even when I knew that my friends were out enjoying themselves. [Note that this is Clare’s real goal. She hopes that psychodynamic intellectual insight will provide the means whereby this goal can be achieved. It is important to distinguish between the means and the goal, and this is what I address in my next response.] Windy: Let me put what you’ve said a little differently. It sounds to me from what you’ve said that your goal is to be able to study even when you know that your friends are out enjoying themselves. You hope that the way to achieve this goal is by finding a reason in your childhood. Have I understood you correctly? Clare: Yes. Windy: Well, I’m happy to work with you towards your goal. However, in REBT, we have a different view on the best way that people can achieve their therapeutic goals. Let me outline the REBT position on this issue. . . [I would then discuss the REBT view of therapeutic change as it pertains to the role of intellectual and emotional insight, namely: that in order to achieve emotional insight into rigid and extreme attitudes it is necessary to examine and change them and then act on them repeatedly.]

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Step 5: Assess the client’s def ined problem using the ABCs of REBT and come to an agreement with them on this assessed problem  As I have dealt fully with the issue of assessing your clients’ problems in Chapters 5–9, I will make only a few points here that are particularly relevant to the topic of goal-­ setting. Remember that the emotional Cs of your clients’ problems will generally be UNEs (see Chapter 6). However, don’t forget that Cs can also be behavioural. It is possible to treat behavioural Cs in two ways. First, you can regard behavioural Cs as actual expressions of action tendencies that stem from UNEs. In this case, you need to target these UNEs for change. Second, you can regard behavioural Cs as stemming directly from your client’s rigid and extreme attitudes and as such they can themselves be targeted for change. As with the defined problem, it is important to agree with your client that your assessment of their problem is accurate. Doing so will help you to set a healthy goal with respect to the assessed problem. Conversely, failing to make such an agreement will lead to difficulties in goal-­setting with respect to the inaccurately assessed nominated problem. Step 6: Elicit the client’s goal with respect to the assessed problem  If you have accurately assessed the specific example of your client’s problem, you will have identified a UNE, a self-­defeating behavioural response and, if relevant, highly distorted subsequent thinking at C, an adversity at A and a set of actual rigid and extreme attitudes and potential flexible and non-­extreme attitudes at B. The next step is for you to elicit your client’s goal, which is based on their assessed problem. This will be in relation to the adversity at A and will usually involve an HNE, a constructive behavioural response and, if relevant, realistic and balanced subsequent thinking at C.

Let me discuss an example based on an assessment of Clare’s defined problem, as discussed above (see p. 107). If you recall, her defined problem with respect to the specific example she chose was: ‘I found it difficult getting down to studying when I knew that my friends were out having a good time.’ My assessment of this problem revealed the following situational ABC: Situation: After planning to spend the evening studying, I heard that my friends had gone out. A = The unfairness of being deprived of the company of my friends when I wanted it. B = I must have fairness in my life at the moment. It’s terrible to be deprived in this unfair way. I can’t bear this unfair deprivation. Poor me! C = Self-­pitying depression and procrastination over studying.

Here is how I helped Clare set a realistic and functional goal with respect to the assessed problem. Note, in particular, that, in keeping with REBT theory, I assume temporarily that Clare’s inferred A is true (see Chapter 7). Thus, I help her to set an emotional and behavioural goal in light of the ‘unfairness’ of the situation. Windy: So, let’s assume that you are in an unfair situation; how is your depression helping you to study? [Note that here I am drawing on Clare’s goal with respect to her defined problem, i.e., ‘To be able to study even when I know my friends are out enjoying themselves.’] 108

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Windy: Right. So what alternative negative emotion will help you to study? [I deliberately phrased my question in this somewhat oblique way to encourage Clare to think hard about the issue.]

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Clare: It’s not. In fact, it’s discouraging me.

Clare: What negative emotion will help me study? I don’t understand. Windy: Well, think about it. You are never going to like the unfairness of the situation, are you? Clare: No, I guess not. Windy: Nor are you likely to be indifferent to it, are you? Clare: No. Windy: So, what’s left? Clare: To feel negative about it. Windy: That’s right, but there are two different types of negative emotions. There are what I call unhealthy negative emotions, which generally inhibit people from adjusting to an adversity or from taking constructive action to change it, and there are healthy negative emotions, which are constructive emotional responses to the same adverse life events and do help people to change these events or make a constructive adjustment if the situation cannot be changed. Now, let’s take your feelings of depression about the unfair situation, where you think that you can’t bear the situation where you need to study when your friends are out enjoying themselves. Is your depression a healthy or unhealthy emotional response? Clare: Clearly it’s unhealthy. Windy: Why? Clare: Because it doesn’t help me to study. Windy: Right. Now, given that you are faced with what you consider to be an unfair situation, what would be a healthy negative emotional response? Clare: To be disappointed or sad about it. Windy: Right. Now, would that be a realistic feeling goal for you? Clare: Yes, I think it would be. Windy: And would it help you to get down to studying when you knew that your friends were out enjoying themselves? Clare: Yes, I think it would. Windy: So let me summarise. When you are faced with the unfairness of your friends going out to enjoy themselves, you want to strive to feel sad or disappointed but not depressed about this and to get down to doing some studying. Is that right? Clare: Yes. Windy: OK, let’s both make a note of that goal and let’s move on to helping you to achieve that goal. . . 109

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As mentioned above, it is also possible to set a goal in respect of your client’s assessed problem, where C is just behavioural. This involves you encouraging your client to set a realistic and adaptive behavioural goal in the face of an adversity at A. In Clare’s case this would be: ‘To get down to studying even when I am faced with the unfairness of staying in when I know that my friends are out enjoying themselves.’

XX Setting a goal with respect to your client’s broad problem Let me begin this section by distinguishing between a broad problem and a specific example of a broad problem. A broad problem tends to be general in nature and probably comprises several different examples. A specific example of a broad problem is just that  – one concrete instance of a broad problem comprising several similar examples. For example, Clare’s broad problem was ‘procrastinating over my studies whenever there is something more attractive to do’. A specific example of Clare’s broad problem was the one discussed at length above, namely: ‘I found it difficult getting down to studying when I knew that my friends were out on Friday night having a good time.’ Many of the issues that I have just dealt with concerning setting goals with respect to specific examples of your clients’ broad problems also emerge when you come to set goals in respect to these broad ­problems. As such I will not repeat myself. What I will do is provide an example of one client’s broad problems and the goals I set with them on the problems.

Problem 1: Feel anxious about approaching women, so don’t do so Goal 1: To feel concerned about approaching women but not anxious about doing so. To approach them despite feeling concerned Problem 2: Feel guilty about past wrongdoings and avoid those who I have wronged Goal 2: To feel remorseful but not guilty about past wrongdoings and make amends where relevant Problem 3: Procrastinate over studies Goal 3: To make a study timetable and keep to it Problem 4: Feel anxious about hosting any kind of gathering in case something goes wrong and therefore avoid being a host Goal 4: To arrange a gathering and feel concerned but not anxious about something going wrong Problem 5: Avoid going to shopping malls because I might feel anxious there Goal 5: To go to shopping malls and feel concerned but not anxious about the prospect of feeling anxious. Then to feel comfortable about going through repeated exposure

I want you to note five things about these goals. 1. All of the goals are within the client’s sphere of influence; that is, they are all achievable. 2. All of the goals indicate the presence of an emotional and behavioural state. It is important therefore to avoid setting goals with your clients that involve the diminution or absence of a state. Thus, instead of the goal ‘to feel less anxious about. . .’ encourage your client to strive ‘to feel concerned, but not anxious about. . .’ Similarly, instead of the goal ‘not to feel guilty about. . .’ encourage your client ‘to feel remorseful, but not guilty about. . .’

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4. All of the goals contain a piece of functional behaviour. 5. One of the goals (i.e., Goal 5) contains an initial healthy negative feeling which then becomes a comfortable feeling state as the result of repeated practice. This last point is important. While it is functional for your client to have a healthy negative emotional response to an adversity, as a counsellor concerned with your client’s long-­term well-­being, you will want them to attempt to change this adversity and increase the number of positive events in their life. This brings us to the third issue concerning goal-­setting in REBT.

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3. Most of the goals contain an HNE in response to a negative activating event. You will also note that while the presence of an HNE is clearly stated, the absence of a UNE is also made explicit.

XX Moving from overcoming disturbance to promoting personal development As I mentioned at the beginning of this chapter, it is possible to think of the goals of psychotherapy as falling into two categories: those to do with overcoming psychological disturbance and those which serve to promote psychological growth or personal development. Overcoming disturbance goals (henceforth called OD goals) relates to the problems (i.e., disturbances) that clients bring to psychotherapy. Thus, when your clients have achieved their OD goals: 1. they experience HNEs when they confront the adversities about which they previously disturbed themselves, and 2. they are able to take constructive action to try and change these negative events. Personal development goals (henceforth called PD goals), on the other hand, are related to a number of broad criteria of mental health which are not situation-­specific. PD goals, then, generally go well beyond OD goals. Although helping clients towards PD goals is beyond the scope of this book, it is important for you to realise that doing so is a legitimate task for REBT therapists. We outline REBT’s view of some of the major criteria of mental health in Table 10.1 to give you some idea of what helping your clients to pursue PD goals might involve for them (for a fuller discussion of REBT’s position on these criteria consult Dryden, 2011b).

Table 10.1  Examples of Mental Health Criteria from an REBT Perspective 1. Enlightened self-­interest Here, the person basically puts themselves first and puts the interests of significant others a close second. Sometimes, however, the person will put the interests of others before their own. Enlightened self-­interest is therefore a flexible position and contrasts with selfishness (the dogmatic position, where the person is only concerned with their own interests and is indifferent to the interests of others) and selflessness (the position where the person always puts the interests of others before their own). 2. Flexibility Here, the person is flexible in their thinking, open to change, free from bigotry and pluralistic in their view of other people. They do not make rigid, invariant rules for themselves and others. 3. Acceptance of uncertainty Here, the person fully accepts that we live in a world of probability and chance, where absolute certainties do not and probably will never exist. (Continued )

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Table 10.1  (Continued) 4. Commitment to vital absorbing interests Here, the person is likely to be healthier and happier when they are vitally absorbed in personal projects outside themselves than when they are not. These interests should be large enough to be involving and allow the person to express their talents and capacities. 5. Long-­range hedonism Here, the person tends to seek a healthy balance between the pleasures of the moment and those of the future. They are prepared to put up with present pain if doing so is in their best interests and is likely to lead to future gain.

In general, you will help your client to work towards their OD goals before raising the issue of PD goals. In my experience, most of your clients will wish to terminate therapy once they have achieved their OD goals. In this respect, Maluccio (1979) found that clients were far more satisfied with what they achieved from therapy on termination than were their therapists. So don’t be surprised if most of your clients are not interested in working towards personal development, and don’t regard this as a failure on your part if this is the case. In the next chapter, I will discuss how you can capitalise on goal-­setting by encouraging your clients to commit themselves to achieving their goals.

Eliciting your client’s commitment to change XX Introduction It is not sufficient to elicit your client’s goals. It is also important to elicit their commitment to change and work towards these goals. Therefore, in this chapter, I will discuss a method which you can use which is helpful in eliciting client commitment to change. For your client to commit themself to change, it is important for them to see clearly that it is in their best interests to make the change. If your client does not see this, then they are hardly likely to commit themself to work towards their stated goal. You might ask why your client might come up with a goal to which they are not committed. There may be a number of reasons for this. First, your client might identify a goal which others want them to achieve, but which they are either opposed to or ambivalent about. Thus, your client’s parents may want them, for example, to become independent, whereas they may wish to stay dependent or be in two minds about becoming independent. In order to help your client to commit themself to a goal, it is important to help them first evaluate fully the advantages and disadvantages of both the problem state and the alternative goal state. Over the years I have experimented with a number of ways of doing this. Having made several modifications to my approach of helping clients to weigh up the pros and cons of change, I now use a method that is quite comprehensive. I have devised a form called the cost–benefit analysis form (CBAF), which I encourage clients to complete, especially when it is clear that a client is ambivalent about change.

Eliciting your client’s commitment to change

◀  CHA P T E R E L E V E N  ▶

XX The cost–benefit analysis form (CBAF) General principles The CBAF, which appears in Figure 11.1, is easy to complete and is based on a number of principles. 1. There is an alternative to your client’s problem and it is important for you to help them to put this in their own words. 2. The problem and the goal both have actual and perceived advantages and disadvantages. 3. These advantages and disadvantages operate both in the short term and in the long term. 4. These advantages and disadvantages are relevant both for your client and for relevant others in their life. This relevance is at its most obvious when your client’s problem is interpersonal in nature;

Fundamentals of Rational Emotive Behaviour Therapy: A Training Handbook, Third Edition. Windy Dryden. © 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.

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however, even when the problem does not seem to involve anybody else, it is still worthwhile asking your client to consider the advantages and disadvantages for themselves and for others. It is important to ask your client to complete the CBAF when they are in an objective frame of mind. Otherwise, you will receive an analysis heavily influenced by their psychologically disturbed state. You may profitably help your client by encouraging them to fill in the form in a session until they understand how to complete it. Then they can finish the form as a homework assignment. For them to complete the form with you present in a therapy session is not a cost-­effective use of session time. Suggest to your client that once they have completed the form, they put it away until the next therapy session. Otherwise, they may ruminate on it in an unproductive way. When you go over the form with your client in the following therapy session, first ask them to state what they learnt from doing the task. If in their answer they state clearly that the goal is more attractive than the problem, you can then ask them to commit themself formally to the goal. This may involve the person making a written commitment which you could both sign. It could also involve them making a public declaration of some kind indicating their commitment to achieving the goal. While making one or both types of formal commitment is not a necessary part of the REBT change process, these procedures do bring home to your client that change is a serious business and one that is not to be entered into lightly. COST–BENEFIT ANALYSIS ADVANTAGES/BENEFITS OF Option 1 SHORT TERM For yourself 1: _______ 2: _______ 3: _______ 4: _______ 5: _______ 6: _______ LONG TERM For yourself 1: _______ 2: _______ 3: _______ 4: _______ 5: _______ 6: _______ DISADVANTAGES/COSTS OF Option 1 SHORT TERM For yourself 1: _______ 2: _______ 3: _______ 4: _______ 5: _______ 6: _______ LONG TERM For yourself 1: _______ 2: _______ 3: _______ 4: _______ 5: _______ 6: _______

For other people 1: _______ 2: _______ 3: _______ 4: _______ 5: _______ 6: _______ For other people 1: _______ 2: _______ 3: _______ 4: _______ 5: _______ 6: _______

For other people 1: _______ 2: _______ 3: _______ 4: _______ 5: _______ 6: _______ For other people 1: _______ 2: _______ 3: _______ 4: _______ 5: _______ 6: _______

Figure 11.1  The cost–benefit analysis form (CBAF). 114

For other people 1: _______ 2: _______ 3: _______ 4: _______ 5: _______ 6: _______ For other people 1: _______ 2: _______ 3: _______ 4: _______ 5: _______ 6: _______

For other people 1: _______ 2: _______ 3: _______ 4: _______ 5: _______ 6: _______

Eliciting your client’s commitment to change

COST–BENEFIT ANALYSIS ADVANTAGES/BENEFITS OF Option 2 SHORT TERM For yourself 1: _______ 2: _______ 3: _______ 4: _______ 5: _______ 6: _______ LONG TERM For yourself 1: _______ 2: _______ 3: _______ 4: _______ 5: _______ 6: _______ DISADVANTAGES/COSTS OF Option 2 SHORT TERM For yourself 1: _______ 2: _______ 3: _______ 4: _______ 5: _______ 6: _______ LONG TERM For yourself 1: _______ 2: _______ 3: _______ 4: _______ 5: _______ 6: _______

For other people 1: _______ 2: _______ 3: _______ 4: _______ 5: _______ 6: _______

Figure 11.1  (Continued)

You will note that I do not advocate going over the CBAF in detail with your client when they have stated that their goal is more desirable than the problem state and that they do wish to commit themself to achieving it. However, if you study the form carefully you will frequently gain a lot of information, especially from the ‘advantages of the problem’ section and the ‘disadvantages of the goal’ section concerning likely obstacles to client progress. Therefore, it is important that you retain a copy of the client’s form and that you have it to hand when you are seeing them. It is also helpful if you encourage your client to keep a copy of the form to hand whenever they come to therapy and at other times. Later, you will want to ask the client to consult it for clues concerning obstacles to their c­ontinued progress. When your client has completed the CBAF and is ambivalent about change or opts for the problem state over the goal state, then you need to go over the form with them in great detail. The purpose of doing this is to discover and deal with the so-­called ‘advantages’ of the problem and ‘disadvantages’ of achieving the goal (I am assuming here that the goal is a healthy one, at least when taken at face value). Unless you deal with these sections of the form and correct the misconceptions you find there, it is not in the interests of either yourself or your client to ask them to commit themself to the goal. To do so under such circumstances is to get the change process off on the wrong foot. The following is an example of how to deal with such a situation. I will first present the client’s CBAF (see Figure 11.2), then I will demonstrate 115

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COST–BENEFIT ANALYSIS ADVANTAGES/BENEFITS OF SULKING

ADVANTAGES/BENEFITS OF SULKING

SHORT TERM

SHORT TERM

For yourself

For other people

1.

‘Safety valve’ for anger

1.

Lets people know I’m angry

2.

Gives me time to think

2.

Draws people’s attention to a problem or mood

3.

Release of frustration

3.

Can jolt people into realising that their behaviour does have a negative effect

4.

Shows dissatisfaction

4.

__________

5.

It’s a sign of annoyance

5.

__________

6.

6.

__________

LONG TERM

LONG TERM

For yourself

For other people

1.

None

1.

None

2.

__________

2.

__________

3.

__________

3.

__________

4.

__________

4.

__________

5.

__________

5.

__________

6.

__________

6.

__________

DISADVANTAGES/COSTS OF SULKING

DISADVANTAGES/COSTS OF SULKING

SHORT TERM

SHORT TERM

For yourself

For other people

1.

It’s a waste of energy

1.

It causes an uncomfortable atmosphere

2.

It’s debilitating

2.

It creates tension in my relationships

Figure 11.2  Sandra’s completed cost–benefit analysis form (CBAF).

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It hides the real problem

3.

__________

4.

__________

4.

__________

5.

__________

5.

__________

6.

__________

6.

__________

LONG TERM

LONG TERM

For yourself

For other people

1.

It puts me in a bad light with others

1.

It causes a lot of misunderstandings

2.

__________

2.

__________

3.

__________

3.

__________

4.

__________

4.

__________

5.

__________

5.

__________

6.

__________

6.

__________

Eliciting your client’s commitment to change

3.

ADVANTAGES/BENEFITS OF COMMUNICATING MY FEELINGS HONESTLY TO OTHER PEOPLE

ADVANTAGES/BENEFITS OF COMMUNICATING MY FEELINGS HONESTLY TO OTHER PEOPLE

SHORT TERM

SHORT TERM

For yourself

For other people

1.

Brings problems to a head

1.

Brings problems to a head

2.

Releases pent-up anger

2.

Clarifies matters

3.

May help to resolve matters

3.

May help to resolve matters

4.

__________

4.

__________

5.

__________

5.

__________

6.

__________

6.

__________

LONG TERM

LONG TERM

For yourself

For other people

1.

Shows a determination to resolve matters

1.

Allows for compromise

2.

Represents more mature and positive action

2.

__________

3.

__________

3.

__________

4.

__________

4.

__________

Figure 11.2  (Continued) 117

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5.

__________

5.

__________

6.

__________

6.

__________ DISADVANTAGES/COSTS OF COMMUNICATING MY FEELINGS HONESTLY TO OTHER PEOPLE

DISADVANTAGES/COSTS OF COMMUNICATING MY FEELINGS HONESTLY TO OTHER PEOPLE SHORT TERM

SHORT TERM

For yourself

For other people

1.

May say things I may regret

1.

Heightens excitability and emotionalism

2.

I may lose relationships

2.

They may feel hurt

3.

__________

3.

__________

4.

__________

4.

__________

5.

__________

5.

__________

6.

__________

6.

__________

LONG TERM

LONG TERM

For yourself

For other people

1.

May become unpopular

1.

They may become wary of me

2.

I may lose relationships

2.

They may decide I’m too unpleasant to be around

3.

__________

3.

__________

4.

__________

4.

__________

5.

________

5.

__________

6.

__________

6.

__________

Figure 11.2  (Continued)

how to challenge their misconceptions about the perceived advantages of the problem and the perceived disadvantages of achieving the goal. I will call the client in this example Sandra. As you can see from Figure 11.2, Sandra is ambivalent about giving up ‘sulking’ (which is her general problem) and opting for the alternative ‘communicating my feelings honestly to other people’, which is Sandra’s stated goal with respect to the general problem of sulking. While you will most often use the cost–benefit analysis method with your client’s general problems and goals, you can also use it with specific examples of general problems and related goals.

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As Sandra is ambivalent about change it is important that I, as her therapist, review the form with her and respond in particular to the advantages she sees accompanying ‘sulking’ (her problem) and to the disadvantages that she sees accompanying ‘communicating my feelings honestly to other people’ (her stated goal). In Figure 11.3, I outline a summary of the specific arguments I used with Sandra as I challenged the misconceptions on which these ‘advantages’ and ‘disadvantages’ appeared to be based. As I will demonstrate later in the chapter, the way I helped Sandra to question her reasoning on this issue was by asking Socratic-­type questions. The summary nature of the arguments presented in Figure 11.3 makes it appear that I just told Sandra why she was in error. As you will soon see, this was far from the case. Note that in my work with Sandra, she refers to unhealthy anger as ‘anger’ and to healthy anger as ‘annoyance’. Using Socratic questions to help your client rethink the perceived advantages of the problem and the perceived disadvantages of the stated goal You will note that many of the arguments that I used with Sandra are directed at her distorted inferences. Thus, taking the short-­term ‘advantage’ of sulking providing a good way of showing dissatisfaction, I showed Sandra that while this may be so, there are better ways of doing so. I also showed her that sulking may lead to greater problems that she has not considered. Once again, it is very important for you to realise that the arguments presented in Figure 11.3 are summaries. That is why they appear in didactic form. In actuality, I engaged Sandra in a Socratic dialogue on the issue, as the following interchange shows.

Eliciting your client’s commitment to change

Responding to your client’s perceived advantages of the problem and perceived disadvantages of achieving the goal

Windy: OK, Sandra. Now, you say that a short-­term advantage of sulking is that it helps you to show dissatisfaction. Do you see any way of showing dissatisfaction without sulking? Sandra: Well, letting people know honestly that I am dissatisfied will have the same effect. Windy: Right. Incidentally, if you sulk how do you know that in people’s minds you are not showing other things, too, like anger or being punitive? Sandra: I guess I don’t. Windy: So which is a more reliable guide to showing dissatisfaction: sulking or honestly communicating your feelings? Sandra: Honest communication. Windy: Does that change your view that a short-­term advantage of sulking is that it helps you to show dissatisfaction? Sandra: Yes. It helps me to see that sulking shows a number of things other than dissatisfaction and these other things like anger won’t be beneficial to my relationships.

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SHORT-TERM ADVANTAGES/BENEFITS OF SULKING For yourself Windy’s response 1. ‘Safety valve’ for anger 1. Controlled honest communication is a more effective way of channelling anger. It is even more effective if you first examine your unhealthy anger-creating rigid and extreme attitudes leading to healthy anger. 2. Gives me time to think

2. You don’t need to sulk to give you time to think. There is a difference between withdrawing for yourself in order to give yourself time to think and withdrawal ‘against the other’, which is what sulking is. In fact, the latter detracts from the quality of your thinking while the former promotes this.

3. Release of frustration

3. When you communicate honestly, you can release frustration, but in a way that is more likely to resolve problems than sulking. 4. While you do show dissatisfaction when you sulk, you show other things, too, which are more likely to cause problems than solve them. When you communicate honestly you show dissatisfaction but again in a more constructive way than sulking.

4. Shows dissatisfaction

5. It’s a sign of annoyance

5. The above argument is also relevant here. Honest communication is a more reliable and healthy way of communicating annoyance than sulking. In keeping the channel of communication open you are more likely to resolve matters by talking them through than with sulking, which closes down the channel. For other people Windy’s response 1. Lets them know I’m angry 1. Sulking may well let others know that you are angry, but it won’t let them know what you’re angry about. It is therefore liable to create more problems in this respect than it will solve. 2. Draws people’s attention to a problem or mood 2. Again, sulking draws their attention to the fact that you have a problem, but it won’t pinpoint the nature of the problem. By communicating honestly and openly you will let other people know exactly what your problem is. 3. Can jolt people into realising that their behaviour 3. This may happen, but what is more likely to happen is does have a negative effect that you will jolt them into realising that your behaviour has a negative effect on them. LONG-TERM ADVANTAGES/BENEFITS OF SULKING None stated

SHORT-TERM DISADVANTAGES/COSTS OF COMMUNICATING MY FEELINGS HONESTLY TO OTHER PEOPLE For yourself

Windy’s response

Figure 11.3  Responding to Sandra’s misconceptions about the ‘advantages’ of her problem and the ‘disadvantages’ of her stated goal.

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1. You are more likely to say things you may regret later when you are unhealthily angry. That is why I recommend that you change the rigid and extreme attitudes that underpin your unhealthy anger to flexible and non-extreme attitudes. Doing so will enable you to be healthily angry instead. Healthy anger is directed at the other’s behaviour, while unhealthy anger is directed at and puts down the other person. 2. I may lose relationships 2. You are more likely to lose relationships if you sulk angrily than if you honestly convey your healthy anger in a firm but caring manner. For other people Windy’s response 1. Heightens excitability and emotionalism 1. If this is a disadvantage for other people,then honest communication of healthy anger will reduce the intensity of the emotional atmosphere, whereas honest communication of unhealthy anger will increase excitability and emotionalism. That is another reason why I recommend that you first identify and examine the rigid and extreme attitudes that underpin your unhealthy anger and replace them with a set of flexible and non-extreme attitudes that will allow you to communicate honestly and firmly, but caringly, your feelings of healthy anger. 2. They may feel hurt 2. Yes, they may feel hurt when you honestly convey your annoyance, even if you choose your words carefully. However, they are less likely to feel hurt when you communicate your feelings of healthy anger than if you communicate your unhealthily angry feelings. Also, don’t forget that other people may feel hurt when you sulk. There is no way of guaranteeing that others won’t be hurt no matter what you do. The more important consideration is whether you want your relationships with others to be based on honest communication or uncommunicative sulking. LONG-TERM DISADVANTAGES/COSTS OF COMMUNICATING MY FEELINGS HONESTLY TO OTHER PEOPLE For other people Windy’s response 1. May become unpopular 1. Yes, you may become unpopular if you honestly communicate your feelings of healthy anger. However, I would argue that in the long term you will be even more unpopular if you sulk or communicate your unhealthy anger. Don’t forget, as well, that honest communication also involves expression of positive feelings. If you are open about your good feelings about others as well as your negative feelings about them, then you will in all probability increase your popularity.

2. May lose relationships

Eliciting your client’s commitment to change

1. May say things I may regret

2. Again, you may lose relationships if you communicate honestly, but if you communicate feelings of healthy anger you will lose fewer relationships in the long term than if you sulk or honestly communicate your otherdamning unhealthily angry feelings. This will especially be the case if you also communicate your positive feelings to other people. Figure 11.3  (Continued)

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For other people 1. They may become wary of me

Windy’s response 1. This is true, but they will probably become equally wary of you when they discover that you sulk. Also, expressions of unhealthy anger are more likely to lead to others being wary of you than expressions of healthy anger. 2. They may decide I’m too unpleasant tobe around 2. This seems to be more a disadvantage for you than for others. Even if it is a disadvantage for them, I would argue, as I have done before, that this is more likely to happen if you sulk or show your unhealthy anger than if you show your healthy anger. Figure 11.3  (Continued)

In order to increase your understanding of how the CBAF can be used, use it with yourself. Choose a personal goal you may be ambivalent about pursuing and use the form to increase your commitment to achieving your goal.

Reconsidering the CBAF and asking your client for a commitment to change After you have helped your client to review the ‘advantages’ of their problem and the ‘disadvantages’ of the stated goal, it is important that you encourage them to reconsider their cost–benefit analysis of the problem and the goal. You can do this in two ways. First, you can have the client take their old CBAF and write in different coloured ink reasons why the perceived advantages of their problems are, in fact, not benefits, and the reasons why the perceived disadvantages of their goal are not, in fact, costs. Second, you can ask your client to complete a second CBAF, which, if you have been successful in helping to correct the previous misconceptions that they made, should demonstrate a clear preference for their stated goal. If not, you need to proceed as above until a clear preference for one of the two options is demonstrated. You will find, in conclusion, that the attitude-­examination process (which is the subject of the following chapters) will go more smoothly when your client has made a commitment to their stated goal than when they are still ambivalent about change. Trying to help your client to examine their attitudes without eliciting such a commitment is like running a race with a ball and chain around one leg. Encouraging your client to make this commitment is the key which removes such an impediment.

Preparing your client and yourself to examine their attitudes It is important to prepare your client for the process of examining their attitudes.1 Novice REBT t­ herapists are sometimes so pleased to have identified an irrational attitude that they launch into disputing it without helping their clients to understand what they are doing, with predictable negative results. Assuming that you have taught your client REBT’s ABC model, assessed their target problem, identified their goal for change and elicited their commitment to work to achieve this goal, what are the preparatory steps that you need to take before you dispute your client’s irrational attitudes? There are two basic steps: (a) helping your client to see the relevance of disputing their irrational attitudes as a means of achieving their goal and (b) helping your client to understand what disputing involves.

XX Helping your client to see the relevance of examining their attitudes as a primary means of achieving their goal After you have helped your client to see that their rigid and extreme attitudes underpin their nominated problem and that their flexible and non-­extreme attitudes will help them to achieve their problem-­ related goal, it is important that you help them to see that changing the former attitudes to the latter is key to goal facilitation. Here is an example of how to do this.

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◀  CHA P TER T W EL V E  ▶

Windy: So, recapping on the ABC of your anxiety, C is your feelings of anxiety, A is the event in your mind that your boss will disapprove of you and B is your rigid and extreme attitude. ‘My boss must not disapprove of me. I am less worthy if he does.’ Is that accurate? Victor: Yes, it is. Windy: From this assessment can you see what largely determines your feelings of anxiety?

1   In traditional REBT terms this is known as disputing the client’s beliefs. As I mentioned in the Introduction, I prefer the term ‘attitudes’ to the term ‘beliefs’. I also prefer the term ‘examine’ to the term ‘dispute’, which suggests a harsher and more adversarial activity. To preserve the letter D in the ABCDE extended framework, I formally use the term ‘dialectical examination of attitudes’, but throughout the book I will use forms of the word ‘examine’. A ‘dialectical examination’ is a method of examining and discussing opposing ideas in order to find the truth. As rigid/extreme attitudes and flexible/non-­extreme attitudes are opposing ideas, ‘­dialectical examination’ is a very apt term here.

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Victor: My attitude that my boss must not disapprove of me and I’m less worthy if he does. Windy: Now let’s recap on your goal. What would be a more healthy but realistic response to receiving disapproval from your boss than anxiety? Victor: As we said before, to feel concerned but not anxious about it. Windy: Right, and when we outlined the ABC of your feelings of concern at the same time as outlining the ABC of your anxiety we developed the following flexible and non-­extreme attitude, which was: ‘I don’t want my boss to disapprove of me but it doesn’t follow that he must not do so. If he does, I am not unworthy. I am the same fallible, complex human being whether he approves of me or disapproves of me.’ Is that accurate? Victor: Yes, it is. Windy: So if your rigid and extreme attitude leads to your anxiety and your flexible and non-­ extreme attitude leads you to feel concerned, which is your goal, what do we have to help you to change in order for you to achieve your goal? Victor: I need to change my rigid/extreme attitude to the flexible/non-­extreme one.

XX Helping your client to understand what examining attitudes involves As I will discuss in greater detail in Chapter 13, examining attitudes involves you asking your client a number of questions designed to encourage them to stand back and examine the truth, logic and pragmatic nature of both their rigid and extreme attitudes and their flexible and non-­extreme attitudes and explaining any points about which they are not clear. As such, it is useful to help your client understand what you will be doing and why you will be doing it. An example follows from my work with Victor.

Windy: Right. You need to change your rigid/extreme attitude to the alternative flexible/ non-­extreme attitude. The way I can best help you to do this is to encourage you to stand back and see which of the two attitudes is true, logical and healthier for you and which one is not and to be able to articulate the reasons for your choice. I will be doing this by asking you a number of questions designed to help you to make your choice of which attitude you want to go on to weaken and which attitude you want to go on to develop. The reason why I will be asking you questions in the first instance is to help you to think about this issue for yourself. This is what Socrates, a famous Greek philosopher, did with his students. He didn’t tell them the answers to various difficult philosophical questions. Rather, he asked them a series of questions, the purpose of which was to help them discover the answers for themselves. He helped them with his questions, to be sure, but he didn’t do the work for them. However, if my questioning doesn’t help you to understand any given point, I will provide you with an explanation which will, I hope, clarify the point. I won’t, in other words, leave you up in the air. Does what I say make sense to you?

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Windy: Shall we start? Victor: Go ahead.

XX How many of the four rigid/extreme attitudes and their f lexible/non-­extreme attitudes should you and your client examine? In training courses on REBT, one of the most frequently asked questions about the process of examining attitudes is: ‘How many of my client’s rigid/extreme and flexible/non-­extreme attitudes should I help my client to examine in an ABC?’ I have already shown you that your client can have up to four rigid and extreme attitudes in any one example of their problems: a rigid attitude, an awfulising attitude, an attitude of unbearability and a devaluation attitude. It follows from this that they can have up to four flexible and non-­extreme attitudes in the same example of what constitutes a healthy solution to the problem: a flexible attitude, a non-­awfulising attitude, an attitude of bearability and an unconditional acceptance attitude. Examining all four pairs is quite time-­consuming and not always necessary. So here are some guidelines for choosing which rigid/extreme and flexible/non-­extreme attitudes to examine in any one example of your client’s nominated problem. Help your client to examine their rigid attitude and alternative flexible attitude unless you have a good reason not to Ellis (1994) has stressed that rigid attitudes, often in the form of demands, are at the very core of ­psychological disturbance. As such, if you follow Ellis’s position, it is very important to examine rigid attitudes and their flexible attitude counterparts. If your client does not see that their rigid attitude has a central role in their disturbance, then help them to examine one or more of their extreme attitudes and non-­extreme attitude counterparts.

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Victor: Yes. What you’re saying is that you will help me to examine both sets of attitudes by asking me questions about them. And you’ll explain any points that I don’t understand.

Help your client to examine their rigid attitude and flexible attitude counterpart and at least one of their three extreme attitudes and their non-­extreme attitude counterparts In my client workbook (Dryden, 2022) I recommend that clients work with a rigid attitude and one of their three extreme attitudes together with their flexible/non-­extreme attitude counterparts, as it is often not feasible and not necessary for them to dispute all four of their rigid/extreme and flexible/ non-extreme attitudes. Other than their rigid attitude (and corresponding flexible attitude), I suggest that you encourage your client to choose whichever one remaining extreme attitude (and corresponding non-­extreme attitude) best accounts for their disturbed reactions at C. Having said this, I have the ­following recommendations to make: ▪▪ Help your client to examine their rigid attitude (and corresponding flexible attitude) and self-­devaluation attitude (and corresponding unconditional self-­acceptance attitude) where their problem is ego-­related in nature.

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▪▪ Help your client to examine their rigid attitude (and corresponding flexible attitude) and other-­devaluation attitude (and corresponding unconditional other-­acceptance attitude) where they are unhealthily angry, this anger is non-­ego-­related in nature and is very much focused on the badness of the other person. ▪▪ Help your client to examine their rigid attitude (and corresponding flexible attitude) and either their awfulising attitude (and corresponding non-­awfulising attitude) or their attitude of unbearability (and corresponding attitude of bearability) in other non-­ego forms of disturbance. ▪▪ Help your client to examine their rigid attitude (and corresponding flexible attitude) and awfulising attitude (and corresponding non-­ awfulising attitude) in non-­ ego anxiety where your client is preoccupied with the prospect of ‘awful’ things happening. ▪▪ Help your client to examine their rigid attitude (and corresponding flexible attitude) and attitude of unbearability (and corresponding attitude of bearability) in non-­ego anxiety where they are scared that they might not be able to bear various states and possible events. ▪▪ Help your client to examine their rigid attitude (and corresponding flexible attitude) and attitude of unbearability (and corresponding attitude of bearability) in non-­ego forms of self-­discipline and in non-­ego features of the addictions. Help your client to examine one of their rigid/extreme attitudes (and flexible/non-­extreme attitudes) when session time is at a premium or that is all they can deal with It sometimes transpires that you only have time to help your client to examine one rigid and extreme attitude (and one corresponding flexible and non-­extreme attitude), or your client, for reason of level of disturbance or level of intelligence, can only process such examination targeted at one of their rigid/ extreme attitudes (and corresponding flexible/non-­extreme attitudes). When this is the case, help the client to examine the one rigid/extreme attitude (with corresponding flexible/non-­extreme attitude) with which the client most resonates, or if they cannot choose, select for them the one rigid/extreme attitude (with corresponding flexible/non-­extreme attitude) they are most likely to change. I hope I have shown in this chapter that while REBT has its preferred attitude-­examining strategies, it allows you a good deal of flexibility in choosing strategies in the light of your client’s response and situation. However, with flexibility comes responsibility. So, become competent at all the attitude-­examining strategies to be discussed in the following chapters so that you can choose the most appropriate strategy for your client in a given situation and offer your skills in executing this strategy. You are now ready for the nuts and bolts of helping your clients to examine their attitudes. I will begin by discussing the three major arguments that you need to use when helping your clients to examine both their rigid/extreme attitudes and their corresponding flexible/non-­extreme attitudes.

Helping your clients to examine their attitudes Helping your clients to examine both their rigid/extreme attitudes and their flexible/non-­extreme ­attitudes is a very important part of REBT. So in this chapter, I am going to show you how you can help your clients to examine both their rigid attitudes and extreme attitudes (awfulising attitudes, a­ ttitudes of unbearability and devaluation attitudes) and their flexible attitudes and non-­ extreme attitudes ­(non-­awfulising attitudes, attitudes of bearability and unconditional acceptance attitudes). By this point, your client should (ideally) have grasped the nature of both sets of attitudes, but if not, then help them to do so (see Chapter 3). The purpose of this chapter is to help your clients to understand fully why their rigid/extreme attitudes are false, illogical and unhealthy and why their flexible/non-­extreme attitudes are true, logical and healthy. This will give them what we call in REBT ‘intellectual insight’ – the knowledge why a particular attitude (e.g., a rigid attitude) is false, illogical and unhealthy and why its alternative (in this case a ­f lexible attitude) is true, logical and healthy. Such knowledge is foundational but will not be sufficient to help your client with their emotional problems because it will not affect their emotions, behaviour and subsequent thinking. Implementing such insight so that they gain ‘emotional insight’ which will affect their emotions, behaviour and subsequent thinking will help them with these problems. Encouraging your client to do the work required of them in this chapter, then, will point them in the right direction but won’t on its own ensure that they will solve emotional problems. Putting intellectual insight into practice and doing so regularly (which will be the focus of the later chapters) will help your clients achieve their problem-­related goals.

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◀  C H APTER T H IRTEEN  ▶

XX The three main arguments The noted American REBT therapist Raymond DiGiuseppe and his trainees once listened to numerous audio tapes of Albert Ellis conducting therapy in order to understand better what I have called here the dialectical examination of attitudes (DiGiuseppe, 1991b). As part of their analysis, DiGiuseppe and his trainees discovered that Ellis employed three major arguments while encouraging his clients to e­ xamine their attitudes. The three arguments that Ellis used were as follows:

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Empirical arguments Empirical arguments are designed to encourage your client to look for empirical evidence that confirms or disconfirms the truth of their rigid/extreme attitudes and their flexible/non-­extreme attitudes. The basic question here is this: are their attitudes consistent with reality or false to the facts? Logical arguments Logical arguments are designed to encourage your client to examine whether or not their rigid/extreme attitudes and their flexible/non-­extreme attitudes are logical. The basic question here is this: are their attitudes logical/make sense or are they illogical/don’t make sense? Pragmatic arguments Pragmatic arguments are designed to encourage your client to question the utilitarian nature of their rigid/extreme attitudes and their flexible/non-­extreme attitudes. The basic questions here are: (a) what are the immediate emotional, behavioural and cognitive consequences of your client’s attitudes and (b) do your client’s attitudes help them or hinder them as they pursue their stated goals? Now that I have described the three major arguments, I will discuss two ways of helping your clients to examine their rigid/extreme and flexible/non-­extreme attitudes: (a) the choice-­based examination method and (b) the use of persuasive arguments.

XX The choice-­based examination method You can employ the choice-­based examination method with your client’s rigid attitude and the flexible alternative to this attitude and/or the most relevant extreme attitude and the non-­extreme alternative to this attitude. While using it you basically ask your client to focus on both attitudes and to choose which is true and which is false, which is logical and which is illogical and which is healthy and which is unhealthy and to give reasons for their choice. This is why the examination process is called dialectical examination, since dialectical means resolving opposing viewpoints through the use of reasoned ­arguments, which is a good description of the purpose of examining attitudes in REBT. Using the choice-­based examination method with rigid and flexible attitudes When using this method with your client’s rigid and flexible attitudes, encourage them to focus on both attitudes and ask them the following questions. ▪▪ Which of these two attitudes is true or consistent with reality and which is false or inconsistent with reality and why? ▪▪ Which of these two attitudes is logical or sensible and which is illogical or nonsensical and why? ▪▪ Which of these two attitudes is largely helpful to you and which is largely unhelpful to you and why? ▪▪ Which of these attitudes do you want to choose to develop going forward and why? Let me show you how I used the choice-­based examination method with Victor with respect to his rigid attitude (i.e., ‘I would prefer my boss not to disapprove of me and therefore he must not do so’) and his corresponding flexible attitude (‘I would prefer my boss not to disapprove of me, but that does not mean that he must not do so’). As I do so, please be aware that I have written both attitudes side by side on a whiteboard visible to both of us.

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Victor: OK. Windy: So, let’s look at the first two attitudes. Attitude 1: ‘I would prefer my boss not to disapprove of me and therefore he must not do so’; and Attitude 2: ‘I would prefer my boss not to disapprove of me, but that does not mean that he must not do so.’ Which of these two attitudes is true or consistent with reality and which is false or inconsistent with reality? Victor: Attitude 1 is false and Attitude 2 is true. Windy: Why is that? Victor: Well, it’s true that I don’t want my boss to disapprove of me, but if it was true that he must not do so, then he would not be able to. He is able to and therefore Attitude 1 is false. Windy: What about Attitude 2? Victor: Well, that is true because both its components are true. It’s true that I don’t want him to disapprove of me and it’s also true that he doesn’t have to do what I want. Windy: OK. Now, which of these two attitudes is logical or sensible and which is illogical or nonsensical?

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Windy: OK, Victor, I am going to ask you some questions about the two attitudes on the whiteboard to see which one you want to move forward with, which you want to let go and the basis of your choice. OK?

Victor: Attitude 1 is illogical and Attitude 2 is logical. Windy: Why? Victor: Attitude 1 is illogical because it does not follow that just because I don’t want my boss to disapprove of me he must not do so. Attitude 2 makes no claims about the relationship between what I want and what has to happen and therefore it is sensible. Windy: OK. Now, which of these two attitudes is largely helpful to you and which is largely unhelpful to you? Victor: Attitude 1 is not helpful to me while Attitude 2 is. Windy: Why? Victor: Attitude 1 leads me to being anxious about my boss disapproving of me. This means that I will spend more time thinking about how I can avoid his disapproval than I will doing my job. Attitude 2 leads me to being concerned but not anxious about my boss’s disapproval. This means that I will take his disapproval in my stride and give all my attention to my work. Windy: Finally, which of these attitudes do you want to choose to develop going forward? Victor: Definitely Attitude 2. Windy: Why? Victor: Well, for all the reasons we have discussed. Attitude 2 is certainly the better attitude for my mental health. Attitude 1 leads to anxiety and obsessiveness.

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Using the choice-­based examination method with extreme and non-­extreme attitudes When using this method with your client’s extreme and non-­extreme attitudes, again encourage them to focus on both attitudes and ask them the following questions. ▪▪ Which of these two attitudes is true or consistent with reality and which is false or inconsistent with reality and why? ▪▪ Which of these two attitudes is logical or sensible and which is illogical or nonsensical and why? ▪▪ Which of these two attitudes is largely helpful to you and which is largely unhelpful to you and why? ▪▪ Which of these attitudes do you want to choose to develop going forward and why? Let me show how I used the choice-­based examination method with Victor with respect to his ­self-­devaluation attitude1 (i.e., ‘My boss’s disapproval means that I am less worthy as a person’) and his corresponding unconditional self-­acceptance attitude (‘My boss’s disapproval is not pleasant, but it does not mean that I am unworthy. I am the same fallible, complex human being whether he approves of me or disapproves of me’). Again, please be aware that I have written both attitudes side by side on a whiteboard visible to both of us.

Windy: Now let’s move on to examining your self-­devaluation attitude (‘My boss’s disapproval means that I am less worthy as a person’) and the corresponding unconditional self-­acceptance attitude (‘My boss’s disapproval is not pleasant, but it does not mean that I am unworthy. I am the  same fallible, complex human being whether he approves of me or disapproves of me’). Both are on the board. I’ll call your self-­devaluation attitude ‘Attitude 3’ and your corresponding unconditional self-­acceptance attitude ‘Attitude 4’. So, which of these two attitudes is true or consistent with reality and which is false or inconsistent with reality? Victor: Attitude 3 is false and Attitude 4 is true. Windy: Why? Victor: Any disapproval I get from my boss does not change me as a person. Windy: OK. Now, which of these two attitudes is logical or sensible and which is illogical or nonsensical? Victor: Attitude 3 does not make sense while Attitude 4 does. Windy: Why? Victor: Well, in Attitude 3 I am saying that my whole self depends on how I am treated by my boss, which is nonsense. In Attitude 4, my view of myself is the same no matter whether my boss approves of me or disapproves of me.

  The same approach can be taken with a client’s awfulising and non-­awfulising attitudes and their attitudes of unbearability and bearability.

1

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Victor: Definitely Attitude 4. Windy: Why? Victor: For the reasons why I want to develop Attitude 2. Attitude 4 is basically much better for my mental health than Attitude 3.

Table 13.1 lists arguments that you can use when helping your clients to examine their rigid/extreme and their flexible/non-­extreme attitudes. These arguments are only illustrative, and as you work with your clients make a note of which arguments they find most persuasive. You may wish to make use of such arguments with them in future. Please note that it is not sufficient for your client to get the right answer to the questions posed in the choice-­b ased examination method: they should also explain the reasons for their answers.

Pair up with a trainee colleague and help them in the role of ‘client’ to examine their rigid ­attitude and flexible attitude using the choice-­based examination method. Suggest that they use a ­personal example or a constructed client example. Record the exchange and note times where you ­struggled to a halt when using this technique. Brainstorm with your ‘client’ ways around your obstacle and consult with your REBT trainer or supervisor where necessary.

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Windy: OK and, finally, which of these attitudes do you want to choose to develop going forward?

Use the choice-­based examination method with one of your ‘client’s’ extreme and non-­extreme attitudes and do the same if you struggle or come to a halt.

XX Use persuasive arguments in the examination process In my opinion, the choice-­based examination method is the most structured way of helping clients to examine both their rigid and flexible attitudes and their extreme and non-­extreme attitudes at the same time. However, it is also important that you help your client to develop their own ways of examining these attitudes, focusing on using arguments that are persuasive to them. Here are a few examples of how to implement this more creative approach to examining attitudes Teach your children Here you take an attitude pair (e.g., a rigid attitude and a flexible attitude) and you ask your client to decide which of the two attitudes they would like to teach to a child or a group of children for whom they have responsibility and/or about whom they care. In teaching the child(ren), please be sure to ask your client to explain the reasons for their choice in terms that the children can understand. Which attitude would you like to have been taught? Take the attitude pairing and ask your client which of these two attitudes would they like to have been taught growing up and why. Also, ask them to make clear why they would not have liked to have been taught the other attitude.

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Table 13.1  Arguments to Use When You Help Your Clients to Examine Their Rigid/Extreme and Flexible/Non-­extreme Attitudes Rigid/extreme attitudes Rigid attitudes vs Flexible attitudes

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When you hold a rigid attitude, you dogmatically attempt to make the world fit your preferences. See that your rigid attitude obstructs you from seeing the world as it is and leads you to hold on to a fixed view of the world. In this way, your rigid attitude is inconsistent with reality. When you hold a rigid attitude, you attempt to extract an ‘ought’ from a ‘preference’, which is illogical. For this reason, your rigid attitude is illogical. Focus on the emotional, behavioural and thinking conse­ quences of your rigid attitude and see that these consequences are unhelpful and unconstructive to you in the long term.

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When you hold an awfulising attitude towards an adversity, you think that (a) nothing could be worse, (b) the adversity in question is worse than 100% bad, (c) no good could possibly come from this adversity, which is wholly bad, and (d) the adversity cannot be transcended. Therefore, your awfulising attitude is inconsistent with reality.

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See that an awfulising attitude has two components: (a) ‘It is bad that the adversity has happened (non-­ extreme)’ and (b) ‘and therefore it is awful’ (extreme). See that it is illogical to try and derive something extreme from what is non-­ extreme and therefore your awfulising attitude is illogical.

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Focus on the emotional, behavioral and thinking consequences of your awfulising attitude and see that these consequences are unhelpful and unconstructive to you in the long term.

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Awfulising attitudes vs Non-­awfulising attitudes

Flexible/non-­extreme attitudes

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When you hold a flexible attitude, you acknowledge what you want and try to get it, but you also accept that this does not have to happen. You do not demand that your preferences are met. This helps you to see the world as it is rather than as you want it to be. In this way, your flexible attitude is consistent with reality. When you hold a flexible attitude, this helps you to see that there is no logical connection between an ‘ought’ and a ‘preference’. For this reason, your flexible attitude is logical. Focus on the emotional, behavioural and thinking consequences of your flexible attitude and see that these consequences are helpful and constructive to you in the long term. When you hold a non-­awfulising attitude towards an adversity, you acknowledge that (a) things can be worse for you, (b) the adversity is thus not 100% bad, (c) you can learn something productive from the adversity, and thus good can come from the adversity, and (d) the adversity can be transcended. No matter how bad it is, it is possible for you to process it and move on with your life. Therefore, your non-­ awfulising attitude is consistent with reality. See that a non-­awfulising attitude has two components: (a) ‘It is bad that the adversity has happened (non-­extreme)’ and (b) ‘but it is not awful that it occurred’ (non-­extreme). See that as both parts of this attitude are non-­extreme, your non-­awfulising attitude is logical since it attempts to derive something non-­extreme from something that is also non-­extreme. Focus on the emotional, behavioural and thinking consequences of your non-­awfulising attitude and see that these consequences are helpful and constructive to you in the long term.

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See that when you hold an attitude of unbearability towards an adversity, you contend at the time that you will die or disintegrate or that you will lose the capacity to experience happiness if the adversity continues to exist. See that both of these contentions are untrue and therefore an attitude of unbearability is inconsistent with reality.

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See that an attitude of unbearability has two components: (a) ‘It is hard to bear the existence of the adversity’ (non-­extreme) and (b) ‘and therefore I can’t bear it if it exists’ (extreme). See that it is illogical to try and derive something extreme from what is non-­ extreme and therefore your attitude of unbearability is illogical. Focus on the emotional, behavioural and thinking consequences of your discomfort intolerance attitude and see that these consequences are unhelpful and unconstructive to you in the long term.

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Focus on the emotional, behavioural and thinking consequences of your discomfort tolerance attitude and see that these consequences are helpful and constructive to you in the long term.

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See that when you hold a devaluation attitude towards an adversity you contend that (a) a person (yourself or other) can legitimately be given a single global rating that defines their essence and the worth of a person is dependent upon conditions that change (e.g., my worth goes up when I do well and goes down when I don’t do well) and/or (b) the world can legitimately be given a single rating that defines its essential nature and that the value of the world varies according to what happens within it (e.g., the value of the world goes up when something fair occurs and goes down when something unfair happens).

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See that when you hold an unconditional acceptance attitude towards an adversity you contend that (a) a person (yourself or other) cannot legitimately be given a single global rating that defines their essence, and the worth of a person is fixed and is not dependent upon conditions that change and/or (b) the world cannot legitimately be given a single rating that defines its essential nature and that the value of the world is fixed and does not vary according to what happens within it.

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Also, see that when you hold a devaluation attitude towards an adversity, you further contend that (c) a person can be rated on the basis of one of their aspects and (d) the world can be rated on the basis of one of its aspects. All these contentions are false and therefore your devaluation attitude is inconsistent with reality.

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Also, see that when you hold an unconditional acceptance attitude towards an adversity, you further contend that (c) a person cannot be rated on the basis of one of their aspects and (d) the world cannot be rated on the basis of one of its aspects. All these contentions are true and therefore your acceptance attitude is true.

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Devaluation attitudes vs Unconditional acceptance attitudes

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See that when you hold an attitude of bearability towards an adversity, you acknowledge that (a) it is hard for you to tolerate it, (b) you can do so, (c) the adversity is worth bearing, (d) you are worth bearing it for, (e) you are willing to bear the adversity, (f ) you commit to doing so and (g) you implement this commitment behaviourally. As all of these components are true, your attitude of bearability is consistent with reality. See that all seven of the above components are non-­extreme and are logically linked together by being non-­ extreme. Given this, your attitude of bearability is logical.

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Attitudes of unbearability vs Attitudes of bearability

(Continued)

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Table 13.1  (Continued) Rigid/extreme attitudes

Flexible/non-­extreme attitudes

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See that a devaluation attitude has two components: (a) a ‘negatively evaluated aspect’ component which acknowledges that it is possible and realistic to evaluate a part of a person or what has happened to that person and (b) an ‘asserted devaluation’ component which claims that you can devalue the whole of a person or the world. Attempts to rate the whole on the basis of a part is illogical and is known as the ‘part– whole error’. As such, a devaluation attitude is illogical.

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Focus on the emotional, behavioural and thinking consequences of your devaluation attitude and see that these consequences are unhelpful and unconstructive to you in the long term.

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See that an unconditional acceptance attitude has three non-­extreme components: (a) a ‘negatively evaluated aspect’ component which again acknowledges that it is possible and realistic to evaluate a part of a person or what has happened to that person, (b) a ‘negated devaluation’ component which asserts the idea that it is not possible to evaluate globally a person or life conditions and (c) an ‘asserted unconditional acceptance’ component which holds that the presence or absence of the adversity does not change the fact that the person is fallible, unrateable, complex and everchanging, and that life is complex, unrateable and everchanging. Given this, see that all three of the above components are non-­extreme and are logically linked together by being non-­ extreme. Consequently, an unconditional acceptance attitude is logical. Focus on the emotional, behavioural and thinking consequences of your unconditional acceptance attitude and see that these consequences are helpful and constructive to you in the long term.

Do the same with your colleague taking an extreme attitude and corresponding non-­extreme attitude.

Use diagrams Some clients are more receptive to points being made visually than verbally. Where this is the case, draw a diagram that would help your client to accept the flexible/non-­extreme attitude rather than the rigid/ extreme attitude. An example of this is shown in Figure 13.1, which shows the ‘Big I–little i’ technique. This technique demonstrates that our ‘self’ (or ‘Big I’) comprises a myriad of different aspects, or ‘little i’s’, and that the self cannot be defined by any of its aspects. SELF

H e l p i n g yo u r c l i e n t s to   e x a m i n e t h e i r  at t i t u d e s

Pair up with a trainee colleague, who adopts the role of ‘client’. Have them take a rigid attitude and flexible attitude counterpart – either their own or one that is constructed – and discuss what arguments they may find persuasive. At the end of this piece of work ask yourself what you can take away from the exercise that you can use in your client work.

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Figure 13.1  ‘Big I–little i’ technique.

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Please remember what I said at the beginning of this chapter: the point of helping your client to e­ xamine their attitudes at this point of the process is to help them gain intellectual insight into the fact that their rigid/extreme attitudes are inconsistent with reality, illogical and largely unhelpful, while their flexible and non-­extreme attitudes are consistent with reality, logical and largely helpful. Having said that, I suggest that you encourage your clients to examine your attitudes regularly, ­devoting about 30 minutes a day to this activity. After they have done this, you can encourage them to write down their relevant flexible/non-­extreme attitudes on cue cards and review them several times a day and also on occasions when they would otherwise disturb themselves. If they thoroughly learn the arguments outlined in this chapter, their use of cue cards will begin to be meaningful, and the ­intellectual nature of the exercise will be replaced with something more emotionally engaging.

XX Dealing with clients’ doubts, reservations and objections to developing f lexible and ­non-­extreme attitudes and letting go of rigid and extreme attitudes An important part of the attitude-­examination process is helping your client to identify and deal with their doubts, reservations and objections (known as DROs) to developing flexible and non-­extreme attitudes and letting go of their rigid and extreme attitudes. If you help your client to respond effectively to any DROs that they may have then this will free them up to get the most from REBT. In this section, I will consider the two major DROs that clients have to adopting each of the four major flexible/non-­extreme attitudes, which I first discussed in Chapter 1, and to giving up each of the four alternative rigid/extreme attitudes. I will offer responses that you can tailor in your work with clients. As such, I have presented so that I (the REBT therapist) am talking directly to the client who is expressing a DRO. Please note that while the responses are didactic in nature (given the restrictions of a book), in your work with clients you will want to use more Socratic methods when dealing with DROs. DRO to adopting a flexible attitude and to giving up a demand Doubt 1: My rigid attitude motivates me to achieve what I want, while the flexible attitude does not. Therefore, if I give up my rigid attitude in favour of my flexible attitude, I’ll lose the motivation to do what is important to me  Response: If this were true then I can understand why you would be reluctant to give up your rigid attitude and work towards gaining conviction in your flexible attitude. However, your ­contention is not the case. Let me put it this way. Your rigid attitude comprises a preference component (e.g., ‘I want to do well in my upcoming test’) and a rigid component (‘and therefore I must do so’). Now, the preference component provides you with healthy motivation in that it leads you to focus on and execute all the tasks that you need to fulfil your desire (e.g., organising your study materials, revising these materials and testing yourself to determine your grasp of what you are to be tested on). The rigid component, on the other hand, will either provide you with unhealthy motivation, sidetrack you or lead you to freeze. Let me consider these effects one at a time. First, your rigid component will provide you with unhealthy motivation. Since you hold the rigid attitude that you absolutely have to pass the test, you will devote all your energies to studying and neglect other important activities like sleep, rest and recreation that will actually help you to get the most out of your studies. You will likely end up too exhausted to concentrate properly and on the day of the test forget much of what you have learnt. Second, the rigid component will interfere with you carrying out effective study and revision strategies and lead you to concentrate on task-­irrelevant thoughts. Thus, you may become overly concerned with the likelihood of failure, exaggerate the consequences of failure and think that the responses of other people to your failure will be highly negative. I hope that you can see that such thoughts are hardly conducive to effective study and t­ est-­taking

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Doubt 2: My rigid attitude indicates what is very important to me, while the alternative flexible attitude fails to do this. Thus, if I give up my rigid attitude in favour of my flexible attitude then I will be giving up on what is really important to me  Response: Your rigid attitude does indicate what is really important to you, but it mainly indicates that you are rigid and dogmatic about what is important to you. For example, if you hold the following rigid attitude: ‘I want to be treated fairly by my boss and therefore he absolutely must do so,’ you are indicating two things. You are indeed indicating that being treated fairly by your boss is really important to you. But you are also indicating that his fair treatment of you is absolutely necessary to you and that you absolutely should be exempt from him treating you unfairly. As I showed you in my discussion of the first doubt, it is the preference component of your rigid attitude that indicates what is important to you (i.e., ‘I really want my boss to treat me fairly’). The rigid component turns what is important to you into a dogma (‘and therefore he absolutely has to treat me fairly’). On the other hand, your flexible attitude indicates in a non-­demanding way what is very important to you. Remember that your flexible attitude has two components: a preference component (‘I really want my boss to treat me fairly’), which demonstrates what you consider to be very important to you, and a negation of the rigid component, which indicates that you have not transformed your strong desire into a rigid attitude (i.e., ‘but sadly this does not mean that he must treat me fairly’). So, giving up your rigid attitude in favour of your flexible attitude does not mean that you are giving up on what is very important. All it means is that you recognise that there is no law of the universe that states that you must get what you hold dear. Also, the preference component of your flexible attitude can be very strong. Thus, I may believe ‘I mildly want my boss to treat me well, but he doesn’t have to do so,’ and if I do then I am indicating that my preference is weak. But I am more likely to hold the attitude ‘I very strongly want my boss to treat me fairly, but that doesn’t mean that he has to do so,’ and when I do I am indicating what is very important to me despite the fact that I am refusing to turn it into a rigid attitude. Thus, a flexible attitude (through its preference component) can and frequently does indicate what you hold very dear. This means that you can surrender your rigid attitude without losing anything except your rigidity.

H e l p i n g yo u r c l i e n t s to   e x a m i n e t h e i r  at t i t u d e s

behaviour. Finally, the rigid component may lead you to become so preoccupied with failing the test that you may freeze and stop revising for the test altogether. By contrast, your flexible attitude comprises a preference component (e.g., ‘I want to do well in my upcoming test’) and a negation of the rigid component (‘but I don’t absolutely have to do so’). Now, as before, the preference component provides you with healthy motivation in that it leads you to focus on and execute all the tasks that you need to actualise your desire. The negation of the rigid component (a) ensures that you don’t get obsessed with passing the test and enables you to take constructive breaks from your preparations, (b) keeps you focused on the task by encouraging task-­relevant thinking and (c) prevents freezing.

DRO to adopting a non-awfulising attitude and to giving up an awfulising attitude Doubt 3: My awfulising attitude shows that what has happened to  me is tragic, while the  non-­ awfulising attitude makes light of this tragedy. Therefore, if I surrender my awfulising attitude in favour of the non-­awfulising alternative, I am making light of what is tragic about my life  Response: This is a commonly expressed doubt, but one that is based on a misconception of what constitutes both an awfulising attitude and a non-­awfulising attitude. In order to make my point, I am going to make an important distinction between the terms ‘tragic’ and ‘awful’ as they are used in REBT. ‘Tragic’ refers to something that has happened in your life that is highly aversive and which has changed your life for the worse, but has not irrevocably ruined it. Although the event is tragic, you can transcend it and go on to

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live a life with some meaning and happiness. ‘Awful’, on the other hand, means that something has happened to you that has irrevocably ruined your life which you cannot transcend. As a result, your life is devoid of meaning and the possibility of happiness. Holding a non-­awfulising attitude enables you to acknowledge that you have experienced something that is tragic but not awful, according to the above definition. This attitude helps you to come to terms with the tragedy and to get on rebuilding your life, whereas holding an awfulising attitude means that you think that effectively your life is over and there is nothing that you can do to rebuild it. I hope that you can see from this discussion that your non-­awfulising attitude does not make light of any tragedy that has befallen you. Indeed, it helps you to acknowledge that a tragedy has happened to you, but gives you hope that you can rebuild your life. While your awfulising attitude shows that what has happened to you is tragic, it turns a tragedy into an end-­of-­the-­world experience, which you can never get over. Therefore, if you surrender your awfulising attitude in favour of the non-­awfulising alternative, you are not making light of what is tragic about your life. You are acknowledging the tragedy and helping yourself to transcend it and to move on with your life. Doubt 4: My awfulising attitude sensibly protects me from threat, while my non-­awfulising attitude ­ eedlessly exposes me to  it  Response: This doubt refers to situations where you experience anxiety. n According to REBT theory, if you hold an awfulising attitude towards something that you perceive to be a threat then you will experience anxiety. You will then tend to act to protect yourself from this ‘threat’, usually by avoiding the threat. This unfortunately means that you will not be able to discover whether or not your perception of threat is accurate. Also, by avoiding the ‘threat’ you will not be able to process it in a healthy manner and thus to develop constructive ways of dealing with it should it turn out to be an actual threat. By contrast, if you hold a non-­awfulising attitude towards something that you perceive to be a threat then you will experience concern. You will then tend to act to protect yourself only if the threat turns out to be real and if you are unable to take constructive action to deal effectively with it. This means that you will not avoid the threat the moment that you perceive the situation to be threatening. Rather, you will stay in the situation to test out your hunch that you are facing a threat and deal with it if you are. Thus, your awfulising attitude may protect you from threat, but it does not do this in a sensible way. In fact, because it influences you to take avoidant action as soon as you perceive a threat, you are likely to continue to perceive threat where none may exist. Also, because you do not learn to take effective action to deal with the threat, you are likely to continue to perceive threat in similar situations. In short, your awfulising attitude may protect you from threat in the short term; however, it increases the likelihood that you will perceive threat in the longer term. Finally, your non-­awfulising attitude does not needlessly expose you to threat. It helps you to remain in the situation long enough to determine whether protective or other action is necessary, and if it is, this attitude helps to determine what constructive action you need to take. DRO to adopting an attitude of bearability and to giving up an attitude of unbearability Doubt 5: If I  adopt my attitude of  bearability, I  will learn to  put up  with adversities. My attitude of ­unbearability discourages me from putting up with these situations. Therefore, I am reluctant to give up my attitude of unbearability in favour of my attitude of bearability  Response: It is true that holding an attitude of bearability enables you to bear an adversity, but it is important that you understand clearly what ‘bearing’ means here. It does not mean putting up with the adversity without attempting to change it. Rather, it means putting up with it while thinking objectively, clearly and creatively about ways of effectively changing it. In other words, holding an attitude of bearability helps you to deal with an

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Doubt 6: My attitude of bearability will expose me to more emotional pain. Therefore, I am reluctant to give up my attitude of unbearability in favor of my attitude of bearability  Response: In the longer term, your attitude of unbearability will increase the chances that your life will become very restricted, dominated by the avoidance of difficult situations and ineffective ways of dealing with these situations. Attitudes of unbearability tend to result in procrastination, anxiety and substance abuse, to name but a few psychological problems. By contrast, your attitude of bearability will help you to deal with the situations about which you experience emotional pain with the result that your emotional pain will be lessened, and when you experience such pain it will based on healthy negative emotions. Attitudes of unbearability, on the other hand, lead you to experience unhealthy negative emotions. So, if your goal is to rid yourself of immediate emotional pain, don’t change your attitude of unbearability. But if your goal is to live a freer, healthier life then change your attitude of unbearability in favour of your attitude of bearability.

H e l p i n g yo u r c l i e n t s to   e x a m i n e t h e i r  at t i t u d e s

adversity. Now, if it transpires that you cannot change this situation, then your attitude of bearability encourages you to put up with it without disturbing yourself about it. By contrast, holding an attitude of unbearability towards an adversity means that you find the situation unbearable. Consequently, you will tend to withdraw from the situation i­ mmediately or take impulsive, unconsidered action to try to change the situation that will, in all probability, make the situation worse. If it transpires that you cannot change the adversity, which is likely given your impulsive attempts to change it, then you will either put up with it while disturbing yourself about it and/or resort to unhealthy ways of distracting yourself from the situation. In conclusion, adopting your attitude of bearability helps you to bear an adversity as a means of changing it if it can be changed, or as a healthy way of adjusting to it if it can’t be changed. By contrast, your attitude of unbearability tends to decrease your chances of changing the adversity and increases the chances that you will disturb yourself in some way if it continues to exist.

DRO to adopting an unconditional acceptance attitude and to giving up a devaluation attitude Doubt 7: Accepting myself unconditionally means that I don’t need to change aspects of myself that I am not happy with or that I can’t change. Devaluing myself, on the other hand, motivates me to change. Therefore, adopting an unconditional self-­acceptance attitude discourages personal change, while keeping my self-­devaluing acceptance encourages such change  Response: You are confusing the term ‘acceptance’ with the terms ‘resignation’ and ‘complacency’. Accepting yourself unconditionally means acknowledging that you are a complex, unique, fallible human being with good aspects, bad aspects and neutral aspects. It means that you can and are advised to identify aspects of yourself that you are not happy with and to change them if you can. Indeed, adopting an unconditional self-­acceptance attitude will help you to change these aspects because it will enable you to devote all your energies to understanding the factors involved and what you can do to change them (e.g., ‘I tend to procrastinate and this proves that I am a fallible human being with good, bad and neutral aspects. Since procrastination is a negative aspect, let me see why I do it and what I can do to stop doing it’). Resignation, on the other hand, means not trying to change negative aspects of yourself because you are sure that you cannot change them (e.g., ‘I tend to procrastinate and there is nothing that I can do to change this’). This is very different from what is meant by unconditional self-­acceptance. Finally, ‘complacency’ means having an ‘I’m all right, Jack’ ­philosophy, which discourages self-­change because there is no need to change anything about you. Again, this is very different from unconditional self-­acceptance. Holding a self-­ devaluation attitude actually discourages self-­ change. Devaluing yourself means ­treating yourself as if you were a simple being whose totality can be rated, rather than as a complex,

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unique, fallible human being who cannot legitimately be given a global rating. It means that when you identify a negative aspect of yourself that you wish to change you devalue yourself for having this aspect (e.g., ‘I tend to procrastinate and this proves that I am an incompetent fool’). Adopting a self-­devaluation ­attitude will stop you from changing your negative aspects because rather than devoting all your ­energies to working to change them, you focus on your negativity as a whole person. Thus, instead of focusing on reasons why you tend to procrastinate and figuring out a way of dealing with these factors, you dwell on what an incompetent fool you are. Thus, your unconditional self-­acceptance attitude has the opposite effect to the one you think it has. It motivates you to change aspects of yourself that you dislike rather than thinking that you don’t need to change them or that you can’t change them. Your self-­devaluation attitude also has the opposite effect to the one you think it has. It prevents you from changing negative aspects of yourself rather than ­motivating you to change them. Doubt 8: Adopting an unconditional other-­acceptance attitude means that I condone that person’s bad behaviour. Devaluing that person shows that I don’t condone their behaviour  Response: When you accept another person unconditionally, you are taking the same stance towards them as you are taking towards yourself when you hold an unconditional self-­acceptance attitude. It means that you are acknowledging that the other person is a complex, unique, fallible human being with good aspects, bad aspects and neutral aspects. Thus, you can unconditionally accept the other person without condoning their behaviour. You can acknowledge that your boss is a fallible human being for treating you unfairly without condoning his unfair treatment of you. This attitude will lead you to take constructive action towards your boss if you think that it is appropriate for you to do so. When you devalue another person, it is true that you do not condone their bad behaviour, but it is also true that you condemn the person for their bad behaviour. Returning to our example, when you hold an other-­devaluation attitude you don’t condone your boss’s unfair treatment of you, but you do regard him as a rotten person for treating you badly. This attitude will stop you from taking constructive action towards your boss and may lead you to take action that is harmful to both you and your boss. In summary, holding an unconditional other-­acceptance attitude does not mean that you condone another person’s bad behaviour. It also has the advantage of promoting constructive action with the ­person who is acting badly. Holding an other-­devaluation attitude also does not lead to condoning the bad behaviour of the other person, but may lead you to act in unconstructive ways towards that person.

Pair up with a trainee colleague and take turns to play the role of ‘client’ and therapist. When in the role of therapist ask your ‘client’ to come up with a DRO to giving up a rigid attitude and developing a flexible attitude. Practise countering their arguments and putting your own forward, and note which ‘client’ arguments you have difficulty countering and which of your arguments are particularly persuasive. Consult with your ‘client’ on the former and consult with your REBT trainer or supervisor where you remain stuck. Repeat this exercise with each of the extreme attitudes and corresponding non-­extreme attitudes.

In the next chapter, I will discuss how you can help your clients to develop their conviction in their flexible and non-­extreme attitudes and weaken their conviction in their rigid and extreme attitudes.

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Helping your clients to strengthen their conviction in their f lexible/non-­extreme attitudes In the previous chapter, I focused on how you can help your clients to examine their rigid and extreme attitudes and corresponding flexible and non-­extreme attitudes. I made the point that the main purpose of the attitude-­examination process at this point was to promote what Ellis (1963) called ‘intellectual insight’, which is an acknowledgement by a client that their rigid/extreme attitudes are false, illogical and unhealthy and their corresponding flexible/non-­extreme attitudes are true, logical and healthy, but which as yet does not have a productive impact on their emotions, behaviour and subsequent thinking. Here, clients say things like: ‘I understand why my flexible/non-­extreme attitude is healthy, but I don’t believe it yet,’ or: ‘I understand that my flexible/non-­extreme attitude is healthy up here (referring to their head) but not down here (referring to their gut).’ In this chapter, I will discuss ways in which you can help your client to develop ‘emotional insight’ into the same issue, but which does have a productive impact on their emotions, behaviour and subsequent thinking. When clients have ‘emotional insight’ they say things like: ‘Not only do I believe it in my head, I feel it in my gut,’ and: ‘I really believe in my heart that my flexible/non-­extreme attitude is true, logical and helpful.’ Put another way, I will suggest methods you can use to help your clients to strengthen their conviction in their flexible/non-­extreme attitudes and weaken their conviction in their rigid/extreme attitudes.

XX Using zigzag techniques with clients When clients embark on the process of strengthening their conviction in their flexible/non-­extreme attitudes, they often find that they counteract this process in their head. In this chapter, I will describe two zigzag techniques which capitalise on your client’s tendency to ‘attack’ their developing flexible/non-­ extreme attitudes and encourage them to respond to these attacks as a way of deepening the process of them strengthening their conviction in their flexible/non-­extreme attitudes. Here, I will show you how to use the written zigzag form (see Figure 14.1) and the recorded version of the zigzag with clients. As I do so, please bear in mind that you should ideally cover this material in a therapy session with your client and then suggest that they practise it for homework (see Chapter 15).

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◀  C H APTER FOURTEEN  ▶

Fundamentals of Rational Emotive Behaviour Therapy: A Training Handbook, Third Edition. Windy Dryden. © 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.

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Flexible / non-extreme attitude

Attack Rating of conviction = % Response

Attack

Response

Attack

Response

Rating of conviction of original flexible/non-extreme attitude = % Figure 14.1  Using the written zigzag form.

Helping clients to complete a written zigzag form The following are my suggestions on how you can help clients best use the written zigzag form (see Figure 14.1). 1. Ask them to write down their flexible/non-­extreme attitude in the top left-­hand box. 2. Ask them to rate their current level of conviction in this attitude on a 100% point scale with 0% = no conviction and 100% = total conviction (i.e., you really believe it in your heart and it would markedly influence your feelings and behaviour) and have them write down this rating in the space provided on the form. 3. Have them attack this flexible/non-­extreme attitude and write it down in the first box on the right. This attack may take the form of a doubt, reservation or objection (DRO) to this flexible/non-­extreme attitude. It should preferably also contain an explicit rigid/extreme attitude. Ask the client to make this attack as genuinely as they can. The more it reflects what they believe, the better. 4. Ask the client to respond to this attack as fully as they can. Stress that it is important that they respond to each element of the attack. In particular, ask them to ensure that they respond to

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5. Encourage your client to continue in this vein until they have answered all of their attacks and cannot think of any more. Suggest that throughout this process they keep the focus on the flexible/non-­ extreme attitude that they are trying to strengthen. If the client finds this exercise difficult, encourage them to make their attacks gently at first. Then, when they can respond to these attacks quite easily, suggest that they begin to make the attacks more biting. Work in this way until they are making really strong attacks. Once the client has got the sense of how to use a written zigzag form suggest that when they make an attack that they do so as if they really want to believe it. And then when they respond, ask them to throw themselves into it with the intention of demolishing the attack and of strengthening their conviction in their flexible/non-­ extreme attitude. If the client makes an attack that they cannot respond to, then they should stop the exercise and raise the issue with you at your next therapy session. 6. When the client has responded to all of their attacks, ask them to re-­rate their level of conviction in the flexible/non-­extreme attitude using the 0–100% scale as before. If your client has succeeded at responding persuasively to their attacks, then this rating will have gone up appreciably. If it has not increased, has only done so a little or has gone down, then suggest that your client do the following. a. Reread what they have written and note: ▪▪ Instances when they went off the point. In such cases suggest that they formulate an alternative response at this point that would have enabled them to keep to the point. ▪▪ Instances when they failed to respond to an element (or elements) of an attack (in particular an unrealistic or distorted inference or a rigid/non-­extreme attitude statement). Again, encourage them to formulate a response to that unanswered element (or elements). ▪▪ Instances when they were not persuaded by their response to an attack. Suggest that they formulate more persuasive ways of responding to this attack in both use of language and content of argument.

Take one of your own flexible and non-­extreme attitudes that you want to strengthen and use the written zigzag form yourself so that you can see what it is like to complete it from the client’s perspective. Share the completed form with a trainee colleague for feedback. If there were any attacks you could not respond to, discuss these with your co-­trainee or your REBT trainer or supervisor.

Helping clients to use a voice recording version of the zigzag technique

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rigid/extreme attitude statements and also to distorted or unrealistic inferences framed in the form of a DRO to the flexible/non-­extreme attitude. Encourage them to do so persuasively and to write down their response in the second box on the left.

Once your client has become proficient at using the written zigzag form, you can suggest that they move on to using the recorded zigzag. The purpose of this variation is the same as in the written zigzag: for your client to strengthen their conviction in their developing flexible/non-­extreme attitudes by responding persuasively to attacks on them. However, as spoken language is used in this variation the client can use their voice tone and the forcefulness of their language to aid them in this process. Indeed, when

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your client uses the recorded zigzag, encourage them to ensure that the force and tone of their voice are more persuasive and their language more evocative when responding to attacks on their flexible/non-­ extreme attitudes than when making these attacks. With this important consideration in mind, I suggest that you use the following steps when helping your client to use the recorded zigzag. 1. Your client will need to use a method of recording their voice. This may be on their smartphone or a good-­quality digital voice recorder. 2. Suggest that they find a time and a place where they will not be interrupted and cannot be overheard. They will need to set aside about 20–30 minutes for this task. 3. Ask them to begin the recording process by stating their flexible/non-­extreme attitude, noting verbally their level of conviction in it, using the 0–100% scale (as above). 4. Have them attack their flexible/non-­extreme attitude on the recording using DROs to this attitude and associated rigid/non-­extreme attitude statements. 5. Ask them to respond to this attack on the recording in a forceful and persuasive manner, making sure that they answer all elements of the attack. In particular, suggest that they respond to the unrealistic aspects of the doubt, etc., and to the associated rigid/non-­extreme attitude statements. 6. Have them go back and forth in this manner (suggesting that they make their responses more forceful and persuasive than their attacks) until they can no longer think of any attacks. Remind them to keep their focus on the flexible/non-­extreme attitude that they are trying to strengthen. 7. Ask them to re-­rate their level of conviction in their originally stated flexible/non-­extreme attitude and state this on the recording. If they have succeeded at responding persuasively to their attacks, then, as with the written zigzag technique, their rating will have gone up appreciably. If it has not increased, has only done so a little or has gone down, suggest that they listen to the recording and note the same instances as I covered above with the written zigzag, responding in the same manner. Remind them that they can discuss any issue with you at their next therapy session. Take one of your own flexible and non-­extreme attitudes that you want to strengthen and use the recorded version of the zigzag technique for yourself. Again, this will help you to experience what it is like to use the technique from the client’s perspective. Play the recording to a trainee colleague for feedback. Once again, if there were any attacks you could not respond to, discuss these with your co-­trainee or your REBT trainer or supervisor

XX Using rational-­emotive imagery with clients Rational-­emotive imagery (REI) is an imagery method designed to help a client practise changing their rigid/extreme attitude to its healthy equivalent while they imagine a specific situation in which they felt disturbed, focusing on what they are most disturbed about. In this way they get imagery-­based experience in deepening their conviction in their flexible/non-­extreme attitude. There are two versions of REI, one devised by Dr Albert Ellis, the originator of REBT, and the other by Dr Maxie C. Maultsby Jr. I will show you how to use both with clients. I will cover the Ellis version first and then the Maultsby technique. Your client may have to use both techniques for a time to determine which is more effective for them.

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How to use REI with clients: Ellis version 1. Ask your client to select a situation in which they disturbed themselves and have them identify the aspect of the situation they were most disturbed about (i.e., the adversity). You should already have done this earlier in the therapy process. 2. Ask your client to close their eyes and imagine the situation as vividly as possible and focus on the adversity. 3. Encourage them to experience fully the unhealthy negative emotion (UNE) that they felt at the time while still focusing intently on the adversity. Ensure that your client’s UNE is one of the following: anxiety, depression, shame, guilt, hurt, unhealthy anger, unhealthy jealousy or unhealthy envy. 4. Instruct your client to experience this disturbed emotion for a moment or two and then change their emotional response to a healthy negative emotion (HNE). Instruct them as they do this to keep their focus intently on the adversity within the chosen situation. Tell them not to change the intensity of the emotion, just the emotion itself. Thus, if their original UNE was anxiety, have them change it to concern; if it was depression, have them change it to sadness. Suggest that they change shame to disappointment, guilt to remorse, hurt to sorrow, unhealthy anger to healthy anger, unhealthy jealousy to healthy jealousy and unhealthy envy to healthy envy. Make it clear that they should change the UNE to its healthy equivalent, but keep the level of intensity of the new emotion as strong as the old emotion. Suggest that they keep experiencing this new emotion for about five minutes, all the time focusing on the adversity. Tell them that if they go back to the old UNE, then they should bring the new HNE back. 5. At the end of five minutes, ask your client how they changed their emotion. 6. Make sure that they changed their emotional response by changing their rigid/non-­extreme attitude to its flexible/non-­extreme alternative. If they did not do so (e.g., if they changed their emotion by changing the adversity to make it less negative or neutral or by holding an indifference attitude towards the adversity), do the exercise with them again and keep doing it until they have changed their emotion only by changing their rigid/extreme attitude to its flexible/non-­extreme alternative. How to use REI with clients: Maultsby version The Maultsby version of REI differs from the Ellis version in one significant respect. In the Ellis version, the client gains practice at changing their UNE to an alternative HNE by changing their rigid/non-­ extreme attitudes to flexible/non-­extreme attitudes implicitly. Thus, they do not bring about emotional change by deliberately and explicitly rehearsing a flexible/non-­extreme attitude. In the Maultsby version of REI, by contrast, the client effects a change in their emotion (from unhealthy negative to healthy negative) by deliberately and explicitly changing their rigid/non-­extreme attitude to an alternative flexible/non-­extreme attitude, as will be shown below. Here is how to use the Maultsby version of REI with clients.

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As I go over both methods, please bear in mind that you should ideally cover this material in a therapy session with your client and then suggest that they practise it for homework (see Chapter 15).

1. Ask your client to identify a specific situation in which they disturbed themself. 2. Have them close their eyes and vividly imagine the situation and focus on the aspect of the situation that they were most disturbed about (i.e., the adversity). Again, you should already have done this earlier in the therapy process.

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3. As they do so, ask them to rehearse their rigid/non-­extreme attitude about the adversity until they experience the one major UNE that typified their disturbance (they should choose from anxiety, depression, shame, guilt, hurt, unhealthy anger, unhealthy jealousy and unhealthy envy) and have them stay with this feeling for a moment or two. 4. While asking them to continue to imagine the same situation and to focus on the adversity, have then change their rigid/non-­extreme attitude to its healthy alternative and have them stay with this new attitude until they experience an HNE at the equivalent level of intensity to the unhealthy equivalent. Your client’s HNE should be the direct alternative to the UNE you identified in step 3 and will be one of the following: concern, sadness, disappointment, remorse, sorrow, healthy anger, healthy jealousy or healthy envy. 5. Ask your client to stay with their flexible/non-­extreme attitude for about five minutes, all the time imagining the situation and focusing on the adversity. If they return to the former rigid/non-­ extreme attitude, instruct them to bring the new flexible/non-­extreme attitude back. If necessary, have them strongly repeat this flexible/non-­extreme attitude until they have made the emotional shift. My final point about REI (either version) concerns how frequently you should encourage your client to practise it. My suggestion is that you suggest your client practises it several times a day and aims for 30 minutes’ daily practice (when they are not doing any other therapy homework). You can suggest that they practise it more frequently and for a longer period of time when they are about to face a situation in which the adversity is likely to occur and about which they are likely to disturb themselves. When your client is doing other REBT homework, 15 minutes’ daily REI practice will suffice.

XX Suggest that your clients teach f lexible/non-­extreme attitudes to others1 Another way in which your client can strengthen their conviction in their flexible/non-­extreme attitudes is to teach them to others. I am not suggesting that they play the role of therapist to friends and relatives, nor am I suggesting that they foist these ideas on people who are not interested in discussing them. Rather, I am suggesting that your client teach flexible/non-­extreme attitudes to people who hold the alternative rigid/extreme attitudes and are interested in hearing what they have to say on the subject. When your client does this, and in particular when the other person argues with the client’s viewpoint in defending their own position, the client gets the experience of responding to the other person’s arguments with persuasive arguments of their own, and in doing so, the client strengthens their conviction in their own flexible/non-­extreme attitudes. Suggest that your client does this after they have developed competence in using the written and recorded versions of the zigzag technique discussed earlier since the back and forth discussion which often ensues when the client attempts to teach flexible/non-­extreme attitudes to others is reminiscent of the zigzag technique.

XX Taking action Perhaps the most powerful way in which your client can strengthen their flexible/non-­extreme attitude is to rehearse it and act on it while thinking in realistic ways that are consistent with it and doing all of this while facing the relevant adversity. When all these systems are working together in sync and your 1   This is different from the ‘teach your children’ method that I described in Chapter 13. That method was theoretical and did not involve the client actually teaching a group of children. This method does involve your client actually teaching somebody a flexible/non-­extreme attitude in person.

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Help the client to plan to face the adversity If your client is truly going to strengthen their conviction in their flexible/non-­extreme attitudes then they are going to have to practise these while facing their adversity at A. When helping my clients to plan to face one of their adversities so that they can rehearse their relevant flexible/non-­extreme attitudes, I ask them to use a principle that I call ‘challenging, but not overwhelming’ (Dryden, 1985). This means suggesting to a client that they select an adversity that they will find a challenge to face but not one that is, at that time, deemed to be overwhelming for them. You may wish to use this principle when working with your clients to help them select an adversity that they can face. Suggest that the client avoids the use of safety-­seeking strategies Once a client has decided to face the adversity at A, and to rehearse their flexible/non-­extreme attitude, it is important that they do not use any strategies that are designed to seek safety in the situation, known as safety-­seeking strategies. To ensure this, review with your client those safety-­seeking manoeuvres that they do use and discourage their use. Suggest instead that they rehearse a relevant attitude of bearability in the face of the discomfort that they will experience when safety-­seeking measures are not employed. Suggest that the client rehearse flexible/non-­extreme attitudes at appropriate points during the facing-­the-­adversity process Taking constructive action in the face of the adversity that features in your client’s problem is an important step, but the real therapeutic value of doing so occurs when the action is designed to strengthen their conviction in their flexible/non-­extreme attitude and weaken their conviction in their rigid/extreme attitude. One way of increasing the chance that their chosen action will do this is for your client to rehearse reviewing the flexible/non-­extreme attitude that they are working to adopt. This rehearsal process can be done at the following times. Before facing the adversity  Before your client enters the situation in which the adversity is likely to occur they can rehearse their flexible and non-­extreme attitude while imagining facing the adversity. I did this when I was overcoming my anxiety about stammering. Before entering a situation where I was likely to stammer, I pictured myself in the situation stammering, and as I did so I rehearsed my flexible/ non-­extreme attitude: ‘I don’t have to be fluent: stammering is bad, but not the end of the world.’ Whether or not the adversity materialises, your client gets some practice at developing their flexible/ non-­extreme attitude in anticipation of it materialising. While facing the adversity  While facing the adversity, the client can repeat to themselves their flexible/non-­extreme attitude and in particular a shortened version of it. I recommend the shortened version of their flexible/non-­extreme attitude when they need to devote much of their attention to the task they are engaged in. Thus, when I was in the situation stammering, I reminded myself that doing so was ‘not awful’.

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client keeps them in sync repeatedly, then they maximise their chances of strengthening their conviction in their flexible/non-­extreme attitudes.

After facing the adversity  After your client has faced the adversity, they can rehearse their flexible/ non-­extreme attitude and consolidate it. Also, if the adversity did not occur even though they put

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t­ hemselves into a situation where they thought it would occur, they can still rehearse their flexible/non-­ extreme attitude. Even when I did not stammer in a given situation, I reminded myself that ‘if I had, then that would have been bad, but not awful’. Help your client to rehearse their flexible/non-­extreme attitude in different ways You can help your client to rehearse their flexible/non-­extreme attitudes while they take action in two basic ways: by varying the audibility of their rehearsal and by varying the strength of their rehearsal. Help your client to vary the audibility of their rehearsal  Suggest to your client that they can vary the audibility of their rehearsal of their flexible/non-­extreme attitude in three ways: 1. out loud, 2. sotto voce or 3. silently in their head. Obviously, when other people are around, your client may not choose to rehearse their flexible/non-­ extreme attitude out loud, but when they are alone, you can suggest that it is a good idea to do so, particularly in the early stages of personal change. When your client is on their own, then, you can suggest that they may wish to begin by stating the flexible/non-­extreme attitude out loud, proceed to repeating it sotto voce before ending up rehearsing it silently in their head. Once they have followed this procedure a number of times, they will probably find that rehearsing the flexible/non-­extreme attitude silently in their mind will suffice. Help your client to vary the strength of their rehearsal  When your client rehearses their flexible/ non-­extreme attitude, you can suggest that they do so at various levels of strength: ▪▪ weakly (e.g., ‘If I stammer, I stammer. Too bad’) ▪▪ moderately (e.g., ‘If I stammer, I stammer. Too bad!!’) ▪▪ strongly (e.g., ‘If I stammer, I stammer. Too f **cking bad!!’). You can suggest that your client rehearses their flexible/non-­extreme attitudes at these varying levels of strength out loud, sotto voce or silently in their head, as shown in the following grid: A Strongly, out loud

B Strongly, sotto voce

C Strongly, silently in their head

D Moderately, out loud

E Moderately, sotto voce

F Moderately, silently in their head

G Weakly, out loud

H Weakly, sotto voce

I Weakly, silently in their head

The more strongly your client rehearses their flexible/non-­extreme attitudes, the better (squares A, B and C). However, as noted above, from a practical point of view, it is not always possible for your client to rehearse their flexible/non-­extreme attitude strongly. For example, if your client is within earshot of others or they need to devote most of their attention to what they are doing, you can suggest to them that they may choose to rehearse their flexible/non-­extreme attitudes moderately or even weakly. At all other times, they will probably find it most persuasive to rehearse their flexible/non-­extreme attitudes strongly.

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You may usefully employ role-­play to help your client to practise acting constructively in ways that are consistent with and therefore help strengthen their conviction in their flexible/non-­extreme attitude. Here, you play the role of a person who, for example, the client is anxious about facing. You first encourage your client to rehearse their flexible/non-­extreme attitude and then you invite them to keep this attitude in mind while they face you in the role of the feared person. I have found that doing this a number of times in the session helps the client deal with difficulties in maintaining their flexible/non-­ extreme attitude and their behaviour that is consistent with it. Help your client to identify and overcome blocks to taking action When it comes to taking action which has been designed to strengthen your client’s conviction in their flexible/non-­extreme attitude, it would be nice if this part of the change process went smoothly. Occasionally it does and your client routinely faces their adversity, takes constructive action while doing so and rehearses the appropriate flexible/non-­extreme attitude. However, it is important to recognise that your client may stop themselves from getting the most out of the ‘taking action’ phase, and when this happens it is important that you both acknowledge that this is the case, and you help your client to identify the block and take steps to overcome it. Here are some of the most common blocks to your client taking action to enable them to strengthen their conviction in their flexible/non-­extreme attitude. Block 1: ‘It’s too hard’  This is perhaps the most common block to your client taking constructive action. It is based on an attitude of unbearability in which your client holds that personal change must either be easy and painless or easier and less painful than it is. Response: An effective response to this block is to encourage your client to do the following: ▪▪ Accept, but don’t like the fact that taking action is often difficult and uncomfortable. ▪▪ Show them that what is difficult and uncomfortable isn’t too difficult or too uncomfortable. ▪▪ Remind them of what they will achieve in the longer term by taking constructive action and what will be the longer-­term consequences of not doing so. ▪▪ Take action. Block 2: ‘I might fail’  When your client refrains from taking constructive action designed to strengthen their conviction in their flexible/non-­extreme attitude, they may do so because they fear that their action may lead to failure. The real block here lies not in the failure itself, but in your client’s attitude towards failure. Here, it is likely that your client holds that they must be successful right from the start, and if their attempts to take constructive action do not bear positive fruit this proves that they are an inadequate person. Response: An effective response to this block is to encourage your client to do the following.

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Use role-­play to rehearse taking action

▪▪ Recognise that taking constructive action in the face of adversity is probably new to them and therefore they may well not immediately succeed when they take such action. ▪▪ If they ‘fail’, encourage them to remind themself that this does not prove that they are inadequate or a failure, but a fallible human being who is able to succeed as well as fail. ▪▪ See their ‘failure’ as an opportunity to learn more about what they need to do to succeed.

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▪▪ Utilise this unconditional self-­acceptance (USA) attitude every time they take action and they don’t get as much from doing so as they’d hoped. ▪▪ Realise that following these steps will increase their chances of strengthening their conviction in their flexible/non-­extreme attitude and that not doing so will result in them retaining their rigid/extreme attitude. Helping your client to deal with blocks to change often involves them seeking out the rigid/non-­ extreme attitude that underpins their block, examining it and acting against it. This is exactly the same procedure as when you help your client to tackle their nominated problem. Bear this in mind when helping them to identify and deal with such blocks. Other blocks  The two blocks that I have discussed above represent the most common examples of an attitude of unbeatability (‘It’s too hard’) and a self-­devaluation attitude (‘I might fail’) respectively. Other common blocks are often examples of one or other of these two attitudes, as I will briefly show below. Block 3: Not facing the adversity  Here your client chooses to face a situation in which the adversity is unlikely to be present or they focus on a different, more positive feature of the situation they are in. Response: Discover whether this subtle avoidance manoeuvre is due to an attitude of unbearability or a self-devaluation attitude. If it is, encourage them to examine the relevant attitude and to go forward on the flexible or non-extreme alternative attitude. They can then face the adversity and rehearse the original flexible/non-extreme attitude in which they are trying to develop stronger conviction. Block 4: ‘I don’t feel conf ident to take action’ Response: Help your client to examine the attitude that they need to be confident before taking action, and have them show themselves that they don’t need this ingredient. Then encourage them to take action unconfidently. Block 5: ‘I’m not sure what will happen if I take action, so I’ll wait until I know’ Response: Help your client to examine the attitude that they have to have certainty before they act, and encourage them to recognise that they don’t need such certainty, even though it would be nice, and that they can take action while feeling uncertain. Encourage them to do so. Block 6: Taking action without rehearsing the flexible/non-­extreme attitude Response: Your client might do this due to an oversight, in which case encourage them to rehearse the attitude the next time they take action. If not, the block might be a version of ‘It’s too hard’ (e.g., ‘It’s too hard for me to take action and rehearse the flexible/non-­extreme attitude at the same time’). This may be realistic and, if so, you may need to help your client to find short-­hand versions of rehearsing their flexible/non-­extreme attitude – for example, by consulting a very short version on a 5×3 cue card or by keeping one key word in mind (e.g., ‘fallible’) which represents the attitude. However, if it is an example of an attitude of unbearability, respond accordingly (see above). The importance of repetition It would be nice, wouldn’t it, if your client could change their rigid/extreme attitude to its flexible/non-­ extreme equivalent by taking constructive action and reviewing the flexible/non-­extreme attitude just once. Sadly, personal change is rarely so easy, and the gains that your client makes as they embark on a

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Pair up with a training colleague and practise the skills of encouraging clients to take action to deepen their conviction in developing their flexible/non-­extreme attitudes. Do so in the following areas: ▪▪ Help the client plan to face the adversity and do so without the use of safety-­seeking strategies ▪▪ Suggest that the client rehearse flexible/non-­extreme attitudes at appropriate points –– Before facing the adversity –– While facing the adversity –– After facing the adversity ▪▪ Help the client identify and overcome blocks to taking action –– ‘It’s too hard’ –– ‘I might fail’ –– Not facing the adversity –– ‘I don’t feel confident to take action’ –– ‘I’m not sure what will happen if I take action, so I’ll wait until I know’ –– Taking action without rehearsing the flexible/non-­extreme attitude ▪▪ Help the client understand the importance of repetition

Much of the work described in this chapter will be done by clients putting into practice what they have learnt in therapy session by agreeing to do homework assignments between sessions. This will be the subject of the next chapter.

H e l p i n g y o u r c l i e n t s t o   s t r e n g t h e n t h e i r c o n v i c t i o n i n   t h e i r f l e x i b l e / n o n - ­e x t r e m e a t t i t u d e s

programme of personal change are usually hard won. Encourage your client to think about the matter like this: ‘Consider how often in the past you have practised in thought and in deed your rigid/extreme attitude that you have now decided to change.’ If your client wants to change their rigid/extreme attitude and strengthen their conviction in the flexible/non-­extreme alternative attitude, it is important that they follow the repetition principle. This simply means carrying out repeated practice at acting constructively in the face of the adversity, while rehearsing their flexible/non-­extreme attitude at appropriate points.

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Negotiating homework assignments As I mentioned at the end of the previous chapter, it is important for your client to put into practice in their everyday life what they learn in therapy sessions. In this chapter, I will discuss several issues that need to be considered when encouraging your client to put their in-­therapy insights into practice outside of sessions.

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◀   C HA P TER F I F TEE N   ▶

XX What’s in a name? Traditionally, REBT therapists call the formal work that clients agree to do between therapy sessions ‘homework assignments’. However, it is not envisioned that your client will only do this work ‘at home’. Rather, your client will carry out such assignments in whatever extra-­therapy context is deemed to be relevant. Thus, the term ‘homework assignment’ means work that your client agrees to do between therapy sessions. While most of your clients will be happy to use the term ‘homework assignment’ when discussing with you the work they are prepared to do on themselves between sessions, it is important for you to appreciate that some clients will find this term off-­putting. The main reason for such antipathy concerns the associations that the term ‘homework assignment’ has with school. In my experience, such clients have negative memories of school in general or homework in particular. For example, one of my clients, Geraldine, associated homework assignments with being locked in her room by her tyrannical mother until she had finished her school homework before being allowed to eat her supper. Not surprisingly, Geraldine reacted negatively to the term ‘homework assignment’ the first time I used it in counselling. Indeed, she winced visibly at the very mention of the term. While there has been no research on the relationship between clients’ reactions to the term ‘homework assignments’ and the extent to which they actually carry out such between-­session tasks, my clinical experience has been that clients are more likely to carry out such tasks when they use positive (to them) terms to denote these tasks. Given that at least some of your clients will have negative reactions to the term ‘homework assignment’, it is important that you develop with them terms that have positive connotations.

Fundamentals of Rational Emotive Behaviour Therapy: A Training Handbook, Third Edition. Windy Dryden. © 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.

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As a training exercise, pair up with a trainee colleague and develop a list of terms other than ‘homework assignment’ that describe the work that your clients need to do between therapy ­sessions if they are to get the most out of REBT. Do this task before you read the next paragraph.

Here is a brief list of terms that I have used with a sample of my clients who reacted negatively to the term ‘homework assignment’: ▪▪ between-­session task ▪▪ change work ▪▪ improvement task ▪▪ goal-­achievement task ▪▪ self-­help assignment ▪▪ progress assignment ▪▪ takeaway task Having made the point that it is important to use a term that enables your client to construe between-­ session work positively, I will use the term ‘homework assignment’ in the remainder of this chapter for ease of communication.

XX Discussing the purpose of homework assignments Bordin (1979) has made the important point that therapeutic tasks need to be goal-­directed if their therapeutic potency is to be realised. As discussed in Chapter 2, one of the most important tasks that your client has to perform in REBT is putting into practice outside therapy what they learn inside therapy. As I have shown above, the best way that they can do this is by carrying out homework assignments. However, as Bordin rightly notes, your client will be unlikely to carry out such assignments if (a) they do not clearly understand the point of doing so in general and (b) they do not clearly understand the specific purpose of specific assignments. As I have already dealt with the issue of helping clients understand the importance of carrying out homework assignments in general earlier in this book, I will concentrate here on the importance of helping your clients to understand the specific purpose of particular homework assignments. The most obvious way of doing this is by keeping the therapeutic focus on your client’s goals. Here is an example of how to do this.

Windy: So, Barry, can you see that as long as you hold the attitude that you must never be rejected you will never ask a girl out for a date? Barry: Yes, that’s self-­evident. Windy: What’s the alternative flexible attitude we developed to this rigid attitude? Barry: That I’d rather not be rejected, but there’s no reason to assume that I must not be rejected.

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Barry: By asking women out for dates. Windy: While practising which attitude? Barry: The flexible attitude I just mentioned. Windy: So do you think it would be a good idea to ask a woman out for a date between now and next week to strengthen this attitude? Barry: OK. Windy: Will you agree to do this? Barry: Yes, I will. Windy: What’s the purpose of doing so?

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Windy: Right. Now, how can you strengthen this flexible attitude?

Barry: To get over my anxiety about asking women out on dates and to get used to rejection if it happens. Windy: That is in fact one of the goals that you mentioned when we discussed what you wanted to gain from counselling. Now, do you think that it would be a good idea to make a note of the homework assignment and the reason why you are going to do it? Barry: Yes, I do.

XX Different types of homework assignments There are different types of homework assignments that you can suggest to your client. We will mention several here, but for a fuller discussion consult DiGiuseppe et al. (2014). Cognitive assignments Cognitive assignments are primarily those which help your client to understand the REBT model and the role that attitudes play in human disturbance and health. They also provide your client with a means of identifying and examining their rigid/extreme and flexible/non-­extreme attitudes and of changing the former to the latter. Many cognitive assignments are thus structured in a way to help your client use the ABCs of REBT to assess their own problems and use attitude-­examination techniques. Normally, doing such assignments on their own helps your client to gain intellectual insight rather than emotional insight into REBT principles. Thus, they serve a very important role in the initial and early–middle stages of therapy. Much of the material that I have dealt with so far in this book can be adapted or tailored for client ­self-­help use. Indeed, I have written an REBT client workbook based on this material (Dryden, 2022). Given this, I will illustrate only two types of cognitive techniques here. Reading assignments  Reading assignments are mainly cognitive in nature in that your client will gain cognitive understanding from such material. Such assignments are frequently known as bibliotherapy. There is a plethora of self-­help books that cover different client problems from an REBT

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­ erspective. Initially, you will want to suggest that your client reads a text which introduces basic REBT p principles. This may be best done after you have taught your client the ABCs of REBT (see Chapter 3). Howard Young (in Dryden, 1989) noted that clients are generally impressed if you suggest that they read a text or an article that you have written yourself, and he thinks that doing so increases the chances that they will read the material. While this awaits empirical investigation, it does make sense, and for this reason I frequently suggest that my clients read Ten Steps to Positive Living (Dryden, 2014), which outlines the basic principles of REBT. If my client expresses alarm at the thought of reading an entire book then I will suggest that they start with the first chapter or I give them copies of the first two chapters of my client workbook Reason to Change (Dryden, 2022), which covers the basics of REBT theory and practice in a manner that is easily digested by most clients. Of course, different clients will benefit from reading different introductory material, and it is worthwhile becoming familiar with introductory self-­help REBT books and articles so that you can suggest the most suitable in each case. They range from the simple – for example, A Rational Counseling Primer, by Howard Young (1974) – to the more linguistically complex – for example, Feeling Better, Getting Better, Staying Better (Ellis, 2001). Later you might suggest that your client reads books or articles that are devoted to their specific emotional problems. I have written specific books on the major unhealthy negative emotions that clients seek help for, including shame (Dryden, 1997b), envy (Dryden, 2002) and guilt (Dryden, 2013b). Another way of approaching REBT bibliotherapy is to suggest that your client reads a book on one or both of the two major forms of psychological disturbance (i.e., ego disturbance and discomfort disturbance). I have written a book on ego disturbance issues entitled How to Accept Yourself (Dryden, 1999) and one on discomfort disturbance issues entitled How to Come Out of Your Comfort Zone (Dryden, 2012). Whichever books or articles you recommend to your client, it is important to note that the purpose of bibliotherapy is to encourage your client to develop intellectual insight into REBT. Many clients believe that if they read and reread articles and books on REBT then they will not only understand these principles but will automatically be able to internalise them into their behavioural and emotional repertoire. As I discussed in Chapter 2, it is very unlikely that this will happen, as internalisation of flexible and non-­extreme attitudes will usually only occur as a result of repeated cognitive, emotive and behavioural practice.

Here are three training exercises that will help you to make effective use of bibliotherapeutic materials. 1. Suggest to your trainee colleagues that you each review three different REBT self-­help books. In doing so, briefly summarise the content of these books and develop a list of indications and contraindications for their use. This exercise will allow you and your colleagues (a) to compile a growing list of REBT reading resources and when they can best be used and (b) to develop your powers of criticism in relation to this material. 2. Begin to write your own REBT self-­help material. This will enable you to increase your credibility with your clients as well as helping them to ‘hear your voice’ in the material that they read. I have found that when my clients say that they can ‘hear my voice’ in the books that I have written, then this helps to reinforce their within-­therapy learning. 3. Pair up with a trainee colleague and as the therapist help your ‘client’ to understand the purposes of reading assignments and, as importantly, the limits of bibliotherapy. As elsewhere, record the interchange and play it to your REBT trainer or supervisor for feedback.

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Listening assignments  Reading assignments obviously involve your client using their visual mode of experience. Some clients, however, may not process information readily using this mode. Others may be blind or find reading the small print of self-­help books or articles difficult because of failing eyesight. Given these points you will need to offer such clients a plausible and effective alternative mode of communication whereby important REBT principles are conveyed. Using the auditory mode of communication is the obvious alternative here, and there are two major types of listening assignments that you can suggest your client does between sessions. First, you can suggest that your client listen to one or more of the numerous CDs and digital downloads that are put out by the Albert Ellis Institute (www.albertellis.org). Most of these are in the form of lectures on client problems (such as anxiety, anger, depression and procrastination) and how these can be tackled using the principles of REBT. Second, you can suggest that your client listens to a recording of their therapy sessions. Numerous clients report that they find listening to such recordings helpful. They frequently say that points that they did not quite understand during a therapy session became quite clear on later review.

There are three reasons why this might be the case. As a training exercise see if a small group of your trainee colleagues can identify them. You may well discover additional reasons. Do this exercise before reading further.

I hope that you were able to discover the three reasons, which I will now discuss. 1. During therapy sessions, your client may be distracted by their own thoughts and feelings related to the problem that they are discussing with you. Such thoughts and feelings will interfere with their ability to process adequately the points you are trying to convey to them using Socratic or didactic means. On later review and freed from the distracting nature of these thoughts and feelings, your client may well be more able to focus on what you were saying than when you said it at the time. 2. During therapy sessions, your client may be reluctant to tell you that they do not understand what you are trying to convey to them. Even when you ask them for their understanding of the points you have been making, their correct response may belie their true understanding. On later review, and freed from the self-­imposed pressure to understand what you are saying, your client may, paradoxically, understand more fully the REBT principles you were explaining. 3. When your client comes to listen to the recording of their therapy session, they can replay the entire session or segments of it as many times as they choose. Unless they ask you to repeat points several times in the session (which the vast majority of clients will not do), your client only gets to hear once what you say in the therapy session. Repeated review of the entire session or salient segments of the session will often facilitate client understanding of REBT principles. Whenever I suggest that clients review recordings of therapy sessions, I suggest that they make written notes as this encourages them to be active in the reviewing process. I particularly ask them to note points that they found most salient and points that they could not understand even after repeated review. I stress that this is most probably attributable to my deficits as a communicator rather than their deficits in understanding what I was trying to convey. Another benefit of encouraging your client to listen to recordings of their therapy sessions is that it helps them to re-­orientate the therapy. Clients sometimes say, for example, that on reviewing the session

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they realised that they were not discussing what they really wanted to discuss or that they had omitted important information while discussing salient issues. In this way, your client may well help you to get therapy back on the most important track. Of course, not all clients will find such listening assignments valuable. In particular, your client may well say that they felt worse after listening to a therapy session than before reviewing it. If this happens regularly, it may well be a sign that you need to suspend the use of this type of homework assignment. Common reasons for clients feeling worse after listening to recordings of therapy sessions usually centre on self-­devaluation issues. Clients may say such things as: ▪▪ ‘I hated the sound of my voice’ (and implicitly – I put myself down for the way I sounded). ▪▪ ‘I hated myself for sounding so pathetic.’ ▪▪ ‘I couldn’t believe how stupid I was for not understanding what you were saying.’ While you may be able to encourage your client to practise an attitude of unconditional self-­acceptance while listening to facets of themselves that they don’t like, most often you will find it more profitable to suspend ‘audiotherapy’ until your client has made more progress on dealing with their self-­devaluation. Here as elsewhere in REBT it is important to be flexible. Imagery assignments When your client uses imagery assignments, they make use of both their cognitive and affective modalities. Imagery assignments are obviously cognitive, although they draw on a different part of the brain to that which processes verbal information. They are also affective in nature because visual images, particularly clear images, are affect-­laden when they embody inferences that are central in the client’s personal domain (see Dryden, 2000). Imagery assignments can be used by your client between sessions as an assessment tool to identify rigid and extreme attitudes that are likely to underpin their predicted disturbed feelings in forthcoming situations. They can also be used by your client as a way of gaining practice in changing unhealthy negative feelings to their healthy counterparts by changing their rigid/extreme attitudes to flexible/non-­ extreme attitudes (see Chapter  14 for an extended discussion of rational-­ emotive imagery (REI) techniques). The important point that your client needs to bear in mind here is keeping the A constant. Otherwise, they may learn that they can change their feelings by changing the actual or inferred A. As I showed in Chapter 2, attitude-­based change is regarded in REBT as more enduring than inference-­based or environmental change. A third way that your client can employ imagery assignments is as a form of mental rehearsal before carrying out behavioural assignments (see Chapter 14). Here, your client is advised to practise seeing themselves in their mind’s eye perform poorly as well as adequately. The purpose of encouraging your client to picture themselves performing poorly is to help them to hold a flexible and non-­extreme attitude towards such an eventuality. Preparing clients for failure as well as success is a typical REBT strategy. While clients differ markedly in their ability to visualise clearly, a more important factor than image clarity in determining the employment of imagery assignments is the presence of client affect accompanying their use. In my view, such assignments are less useful with clients who experience no affect while picturing themselves in situations where they would in reality feel a lot of emotion than with clients who do experience affect while using imagery.

Behavioural assignments involve your client doing something to counteract their rigid/extreme ­attitudes and to consolidate their flexible/non-­extreme attitudes. They are assignments which encourage your client to act on their flexible attitudes and other related non-­extreme attitudes. Given this, behavioural assignments are often used simultaneously with cognitive assignments which provide your client with an opportunity to rehearse their flexible and non-­extreme attitudes. The main purpose of behavioural assignments, then, is to help your client to strengthen their conviction in their flexible and ­non-­extreme attitudes (see the extended discussion of this issue in Chapter 14). ‘Acting as-­ if’ is a useful behavioural assignment that promotes emotional insight. It involves ­identifying specific opportunities for your client to behave ‘as-­if’ they already had a strong conviction in their flexible/non-­extreme attitude. Through enacting the attitude the client wants to strengthen, they will begin to see the benefits of holding this attitude. It is useful to base ‘acting as-­if’ exercises on the action tendencies associated with the healthy negative emotion you and your client have identified as a goal (see Table 4.1, pp. 54–61). A discussion of the full range of behavioural assignments used in REBT is beyond the scope of this handbook, but can be found in Bernard and Wolfe (2000).

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Behavioural assignments

Emotive assignments Emotive assignments are therapeutic tasks that fully engage your client’s emotions. As such, as long as they meet this criterion, certain cognitive and behavioural techniques can be regarded as emotive assignments. Thus, Ellis regarded certain cognitive techniques as emotive in nature when they are employed by clients with force and energy, and he saw certain behavioural techniques such as ‘shame-­attacking exercises’ as emotive because clients are encouraged to do certain ‘shameful’ things and simultaneously ‘attack’ their shame by changing the rigid and extreme attitudes that underpin this emotion. In addition, certain imagery methods, such as REI, can be classified as emotive assignments because they attempt to engage fully your client’s emotions. As with behavioural assignments, the major purpose of emotive assignments is to help your client to turn their intellectual conviction in their flexible/non-­extreme attitudes into emotional conviction (see Chapters 2 and 14).

XX The importance of negotiating homework assignments The field of behavioural medicine has focused much attention on the factors associated with patient compliance with prescriptive medical treatment. However, the term ‘compliance’ is an unfortunate one when used in counselling and psychotherapy as it conjures up the image of an all-­knowing therapist telling the ignorant client what to do, with the client either complying or not complying with these instructions. While it is debatable whether this image is even appropriate in the field of medicine, it is certainly unsuitable in the field of psychotherapy in general and REBT in particular. On the other hand, the image of equal collaboration between therapist and client is also not appropriate in REBT. While the egalitarian-­collaborative model of the therapeutic relationship is appealing to therapists who view their main role as encouraging clients to use their own resources, it is viewed as dishonest by REBT therapists. It ignores, for example, the fact that as an REBT therapist you know more than your client about (a) the nature of psychological disturbance, (b) how clients, in general, perpetuate

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their psychological problems and (c) the processes of therapeutic change and how to facilitate it. Having this knowledge does not entitle you to view yourself as an all-­knowing guru and act accordingly, but neither should it lead you to deny that you have such knowledge in the spirit of well-­meaning but ultimately misguided egalitarianism. As I argued in Chapter  2, REBT theory holds that you and your client are equal in humanity but unequal in knowledge and understanding of human disturbance and its remediation. This view of the therapeutic relationship in REBT underpins the importance of negotiating homework assignments with your client. This means that you neither unilaterally tell your client what they will do for homework, nor wait for them to tell you what they are going to do between sessions. It means that you will have an informed view concerning the best homework assignment for them at a given time, that you will express this view honestly with your client, but you will very much respect their opinion on the matter and will discuss with them your respective views with the purpose of agreeing a homework assignment to which they will commit themselves. Let me illustrate the differences between the three approaches to homework assignments that I have described. I will first set the scene and then vary the dialogue to highlight these differences.

Windy: So, Norman, you can now see that your anxiety about speaking up in class stems from two attitudes: first, the attitude that you must know for certain that you won’t say anything stupid and, second, the attitude that if you do say something stupid then other people will laugh at you, which would prove that you would be stupid through and through. Right? Norman: Right. Windy: And the flexible and non-­extreme alternatives to these two rigid and extreme attitudes are? Norman: That I’d like to be certain that I don’t say something stupid, but I don’t need this certainty. And I can accept myself as a fallible human being in the event of saying something stupid and people laughing at me. Windy: Now, you also understand that if you want to deepen your conviction in these two attitudes, you need to. . .? Norman: Practise acting according to these two attitudes. 1. REBT therapist as unilateral expert: telling a client what they will do for homework Windy: OK, so what I want you to do between now and next week is to speak up five times in class, and practise your two flexible and non-­extreme attitudes before, during and after doing this. Agreed? Norman: [pause] . . . [very hesitantly] . . . A-­A-­Agreed. [As you can see, here I have unilaterally decided what is good for Norman and I have told him what I want him to do. As the very hesitant response of my client shows, he is most unlikely to do this homework or, if he does, it will be out of fear.] 2. REBT therapist as laissez-faire egalitarian: waiting for your client to tell you what they will do for homework Windy: So, Norman, what can you do between now and next week to practise and strengthen these two attitudes?

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Windy: OK, fine. [Here, because I am overly keen to encourage Norman to use his own resources, I do not query his own suggestion. While the client may well carry out this assignment, he will not derive much benefit from it, primarily because it is not a behavioural task.] 3. REBT therapist as authoritative egalitarian: negotiating a homework assignment with your client Windy: Now, Norman, let me make a suggestion about what you can do to strengthen these attitudes and then we can discuss it. OK? Norman: Fine. Windy: First of all, it is important to do something active to get over your fear. Can you see why? Norman: Because if I don’t, I won’t overcome it.

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Norman: Well, I suppose I can think about the ideas once a day.

Windy: Right, so how about speaking up in class while showing yourself before, during and after you do so that you’d like to be certain that you don’t say something stupid, but you don’t need this certainty. And that you can accept yourself as a fallible human being in the event of saying something stupid and people laughing at you? Norman: OK, that sounds reasonable. Windy: How about speaking up every college day between now and our next meeting? Norman: That’s five days! That seems a bit steep. Windy: What would you suggest? Norman: Twice? Windy: How about a compromise of three or four? Norman: Three it is, then. [Note that here I have taken an authoritative stance by selecting for Norman a relevant ­behavioural task. However, I am egalitarian in that I ask him for feedback on my suggestion and I am ­prepared to negotiate a compromise. I thus show that I respect his opinion, but I also ask him to respect mine. My hypothesis is that the client is more likely to carry out this task than he would in the first scenario discussed above when I unilaterally told him what he was to do for homework.]

I discuss the working alliance in REBT more extensively in Dryden (2021b), which is based on the idea of the therapist as an authoritative egalitarian.

XX The ‘challenging, but not overwhelming’ principle of homework negotiation Albert Ellis (1983) was openly critical of many popular behaviour therapy techniques that are based on the principle of gradual desensitisation. Ellis argued that the use of such techniques is inefficient in that it needlessly prolongs the length of therapy and that it tends to reinforce clients’ attitudes of ­unbearability.

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By using gradual desensitisation methods it is as if the therapist is implicitly saying to the client: ‘You really are a delicate flower who can bear virtually no anxiety or discomfort and that is why we will have to take things very gradually.’ Given this, Ellis argued that clients can help themselves best by doing homework assignments based on the principle of flooding or full exposure. Here, your client would practise strengthening their f­ lexible and non-­extreme attitudes by seeking out situations in which they would be most anxious. They would then stay in these situations until they had strengthened their flexible/non-­extreme attitudes to the extent that they no longer felt anxiety. They would then do this frequently and repeatedly until they had overcome their problem. Ellis (1983) described a case where he helped a woman overcome her lift ­phobia by full exposure methods. The woman agreed to travel repeatedly in lifts in a short period of time until she could travel in them without anxiety. It goes without saying that the client needs to be very motivated to do this. Thus, Ellis’s client had just been offered a desired job at the top of a New York skyscraper. Because it was impossible for her to take the stairs, she was faced with the choice of declining the position or travelling in the lift to her new office. When your client has such motivation and is prepared to tolerate the high levels of discomfort to which flooding methods lead, you should encourage them to undertake homework assignments based on the principle of full exposure. However, in my experience, most clients will not agree to carry out such assignments. In such instances, is there a better alternative to homework assignments based on gradual desensitisation? The answer is ‘yes’ and these are assignments based on the principle that I have called ‘challenging, but not overwhelming’ (Dryden, 1985). Such assignments occupy a middle ground between flooding and gradual desensitisation methods. They constitute a challenge for your client, which if undertaken would lead to therapeutic progress, but would not be overwhelming for the client (in their judgement) at that particular time. Here is an example of how I introduce this concept to clients.

Windy: Now, Norman, how quickly do you want to overcome your fear of speaking up in class: very quickly, moderately quickly or slowly? Norman: Very quickly. Windy: And how much discomfort are you prepared to face in overcoming your problem: great discomfort, moderate discomfort or no discomfort? Norman: Well, ideally no discomfort. Windy: So you’d like to overcome your problem very quickly and without discomfort. Right? Norman: Right. Windy: Well, I’d really like to help you to do that but, unfortunately, I can’t. Let me explain. If you want to overcome your problem very quickly, you will have to speak up in class very frequently and this will involve you bearing much discomfort. Here, you will have to do assignments based on the principle of full exposure. However, if you want to experience minimal levels of discomfort, then it follows that you will have to go very slowly. Here, you will do assignments based on the principle of gradual desensitisation. A middle ground between these two positions is based on the principle that I call ‘challenging, but not overwhelming’. Here, you will choose to do homework assignments that are challenging, but not overwhelming for you at any point in time. This would involve you bearing moderate levels of discomfort and would lead you to make progress moderately quickly. Is that clear?

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Windy: That’s exactly right. So, how would you like to proceed? Norman: According to the ‘challenging, but not overwhelming’ principle. Windy: Then let’s see what you can do between now and next week that will allow you to practise strengthening your flexible and non-­extreme attitudes in a way that is challenging for you. . .

Let me make two concluding remarks on this issue. 1. I tend to dissuade any clients who say that they wish to follow the ‘gradual desensitisation’ route. I  point out to them that doing so will be counterproductive in that taking this route will tend to reinforce their attitude of unbearability. However, I do not insist that such clients begin with ‘challenging, but not overwhelming’ homework assignments. If the worst comes to the worst, I would start with the ‘gradual desensitisation’ route, hoping to ‘transfer’ them to the ‘challenging, but not overwhelming’ route as quickly as possible.

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Norman: Yes. You’re saying that I can go slowly, moderately quickly or very quickly. The quicker I decide to go, the more discomfort I will have to tolerate.

2. A number of clients who begin by carrying out ‘challenging, but not overwhelming’ homework assignments do switch to flooding-­type assignments after they have made some progress and they get accustomed to bearing moderate levels of discomfort.

XX How to increase the chances that your client will do homework In the following sections, I want to mention several principles that you can follow to increase the chances that your client will carry out their jointly negotiated homework assignment. Please note, however, that none of these methods will guarantee that they will actually do the assignment. Assuming that you have carried out the following steps, it is important not to lose sight of the fact that your client is ultimately responsible for whether or not they will do their homework. Thus, whether they do so or not is not a measure of your worth as a therapist (or even as a person!). Teach your client the ‘no-lose’ concept of homework assignments The ‘no-­lose’ concept of homework assignments is designed to give your client additional encouragement to agree to carry out an assignment. While introducing the concept to your client you need to stress that there is no way that your client can lose if they agree to undertake the homework task, and you need to emphasise three points, as shown in the following dialogue.

Windy: So to recap, Norman, you have agreed to speak up in class on three occasions while showing yourself (a) that you don’t need to be certain that you won’t say anything stupid before you speak and (b) that if you do say something stupid you can still accept yourself as a fallible human being even if people in your seminar group laugh at you. Is that right? Norman: Well, I’m still a bit doubtful about it.

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Windy: I can appreciate that, but let me put it this way. If you undertake to do the assignment, then there is no way you can lose. Do you know why? Norman: No, why? Windy: Well, let me put it like this. First, if you agree to do the assignment and you actually do it and it works out well, then that’s good because you have made a big stride forward in meeting your goals. Right? Norman: Yes, I can see that. Windy: Second, if you agree to do the assignment and you actually do it, but it doesn’t go well, then that’s valuable because we can analyse what happened and you can learn from the experience. Do you see that? Norman: Yes, I do. Windy: And, finally, if you undertake to do the homework assignment, but you don’t do it, then that is also valuable. Do you know why? Norman: Because we can find out how I stopped myself from doing it? Windy: That’s right. We can discover obstacles, which neither of us knew about, and then we can help you to overcome them. So, can you see why if you agree to do the assignment, you can’t lose? Norman: Very good. You should be a salesman! Windy: I am. I’m trying to sell you on the concept of mental health and how you can achieve it!

Ensure that your client has suff icient skills to carry out the homework assignment It is important that your client has the skills to carry out the negotiated homework assignment. For example, if you have suggested that your client completes a written ABC form, it is important that you first instruct them in its use. They are more likely to do the assignment if they know what to do than if they do not. Ensure that your client believes that they can do the homework assignment Self-­efficacy theory (Bandura, 1977) predicts that your client is more likely to carry out a homework assignment if they believe that they can actually do it than if they lack what Bandura calls an ‘efficacy expectation’. Given this, it is important to spend some time helping your client to see that they are able to carry out the homework task. One way to do this is to suggest that your client uses imagery techniques where they repeatedly picture themselves carrying out the assignment before they do so in reality. It is important to distinguish between an efficacy expectation and the more objective question of whether or not your client has a particular skill in their repertoire. It is possible that your client has a skill in their repertoire but subjectively believes that they are unable to use this skill in a particular setting. Thus, it is insufficient to teach your client a skill such as completing a written ABC form. You also need to help them to develop the relevant efficacy expectation. Here is an example of how to do this.

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Norman: I’m not sure. Windy: Well, let’s see. Close your eyes and picture yourself in class. Have you got that image in mind? Norman: Yes, I have. Windy: Good. Now see yourself showing yourself that you don’t need to be certain that you won’t say anything stupid and that you can accept yourself as a fallible human being if you do. Have you got that? Norman: Yes. Windy: Now keep those two attitudes in mind and see yourself speaking up in class. Can you do that?

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Windy: So do you think you can speak up in class while showing yourself that you don’t need to be certain that you won’t say anything stupid and that you can accept yourself as a fallible human being if you do?

Norman: Yes, I can picture that. Windy: So does this show you that you can do this assignment in reality? Norman: Yes, it does.

Give yourself suff icient time to negotiate a homework assignment I have listened to many therapy sessions conducted by beginning REBT therapists over the years and have been struck by how little time such therapists allocate to negotiating homework assignments with their clients. They frequently leave the issue of homework to the very last minute, with the result that they end up by telling their clients what they want them to do between sessions. Because negotiating a suitable assignment takes time, I suggest that you allocate 10 minutes to this activity. This will enable you to incorporate all of the issues that I have discussed in this chapter, which, I argue, will increase the chances that your client will execute the homework task successfully. If you have negotiated a suitable homework assignment in the early or middle part of a therapy session you will not need to devote 10 minutes to this task at the end of a session. However, it is still worthwhile allocating a few minutes to recap on the homework, otherwise your client may forget what their homework is. This latter point emerged from a book that my colleague Joseph Yankura and I produced on the therapy work of Albert Ellis, entitled Doing RET: Albert Ellis in Action (Yankura & Dryden, 1990). We noted that Ellis did not consistently negotiate specific homework assignments with his clients at the end of a session. Ellis replied that he often makes homework suggestions during a therapy session. The important point here is not whether you did or did not negotiate a homework assignment, but whether your client remembers the homework. When we interviewed several of Ellis’s clients for the book we came away with the impression that Ellis’s clients did not recall that he consistently suggested specific homework tasks. One way to ensure that your client remembers that homework has been negotiated, particularly when this has been discussed in the main body of the session, is to review it at session’s end. Another way of encouraging your client to remember their homework is to suggest that they keep a written record of the assignment. I will discuss this further in a later section.

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Ensure that the homework assignment follows logically from the work you have done with your client in the therapy session Much of the work you will do in a therapy session will be focused on one of your client’s nominated problems. Towards the end of the session, you should ideally negotiate a homework assignment with your client that logically follows from the work you have done with them on their nominated problem. The following is a rough guide of when to negotiate which type of homework assignment. ▪▪ Negotiate a reading assignment when the work you have done with your client has centred on helping your client to understand the relationship between their unhealthy negative emotion and their rigid/ extreme attitudes. ▪▪ Negotiate a written homework assignment (e.g., an ABC form) when the session work has centred on helping your client to examine their rigid/extreme and flexible/non-­extreme attitudes and when you have trained your client in the use of the relevant written form. ▪▪ Negotiate an imagery assignment when the session work has focused on beginning to strengthen your client’s flexible/non-­extreme attitudes but they are not yet ready to undertake a behavioural assignment. ▪▪ Negotiate a behavioural assignment (along with a relevant attitude rehearsal technique) when the session work has prepared your client to strengthen their flexible and non-­extreme attitude by, for example, ‘acting on their flexible attitudes while simultaneously rehearsing them’. ▪▪ Negotiate an emotive assignment when the session has been devoted to discussing how your client can deepen their conviction in their flexible and non-­extreme attitude other than through the use of behavioural assignments. To reiterate, whatever type of homework assignment you negotiate with your client, ensure that it is relevant to the work you have done with them in the session. Ensure that your client understands the nature and purpose of the homework assignment I mentioned this point earlier, but it is so important I wish to reiterate it here. At the end of the process of homework negotiation, it is useful to ask your client to summarise the homework assignment and its rationale. It is particularly important to ensure that your client has understood the reason why they have agreed to carry out the assignment. My clinical experience has shown me that the more a client keeps the purpose of a negotiated homework assignment at the forefront of their mind, the more likely it is that they will do the agreed assignment. Here is an example.

Windy: So let’s recap. What are you going to do between now and next week? Norman: I’m going to speak up in class and practise my new flexible and non-­extreme attitudes. Windy: And what’s the purpose of speaking up in class while showing yourself that you don’t need to be certain that you won’t say anything stupid and that you can accept yourself as a fallible human being if you do? Norman: Well, it will help me to be able to speak up in class whenever I want to say something without feeling anxious.

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If you can help your client to specify the number of times they will carry out the negotiated homework assignment, when they will do it and in what setting, then they are more likely to do it than if no such agreements are made. For example:

Windy: Now, Norman, how many times between now and next week will you agree to speak up in class while practising your flexible and non-­extreme attitudes? I was thinking that four times might be a challenging number, but I don’t want to suggest this if it is too overwhelming for you at this point. Norman: Well, that sounds a bit steep. How about twice? Windy: Shall we compromise on three? Norman: OK, then.

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Help your client to specify when, where and how often they will do the homework task

Windy: And where will you do this? Norman: Well, I’ve got four seminars next week. I can do it in three of those. Windy: Let’s be really specific here. Norman [looking in his diary]: Well, I can do it in the Monday seminar at 3 p.m., in the Wednesday seminar at noon and in the Friday seminar at 10 a.m. Windy: Good. Now let’s talk about when in the seminars you will do this. In my experience it is better to do the homework early in the seminar rather than later. Does that make sense? Norman: Yes, it does. Windy: So would it make sense to speak up in the first 20 minutes of the seminar? Norman: Yes, that makes sense. Windy: Will you do it? Norman: Yes.

Elicit a f irm commitment that your client will carry out the homework assignment It is important to get a firm commitment from your client to do the assignment rather than a vague commitment such as ‘I think I can do that’ or ‘I’ll try.’ When your client makes a definite commitment to do the homework assignment, they are more likely to do it than if they make a vague commitment. For example:

Windy: So would it make sense to speak up in the first 20 minutes of the seminar? Norman: OK. I’ll try to do that. Windy: Let me show you the difference between ‘do’ and ‘try’. Snap your fingers. . . [Norman snaps his fingers]. Now try to snap your fingers, but don’t actually snap them. . . [Norman makes

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the relevant movement but doesn’t actually snap his fingers]. Can you see the difference between ‘try’ and ‘do’? Norman: When you do something you do it. But when you try, it doesn’t mean that you will do it. Windy: So will you commit yourself to speaking up in the first 20 minutes or will you commit yourself to trying? Norman: I’ll do it.

See also Chapter 11, which is devoted to the issue of eliciting your client’s commitment to change. Troubleshoot any obstacles to homework assignment completion It has been my experience that when I have helped my clients to identify potential obstacles to homework completion and to find ways of dealing with these obstacles, then they are more likely to do the homework than when I have not instituted such troubleshooting. What may serve as potential obstacles to homework completion? Golden (1989) has provided a comprehensive list of such obstacles and we refer the reader to his excellent discussion of the subject. Given this, I will only consider here the most common obstacle, which is an attitude of unbearability. Clients often provide many rationalisations in their explanations of why they did not do their homework (e.g., ‘I didn’t have the time’ or ‘I forgot’) when the real reason can be attributed to an attitude of unbearability (e.g., ‘I didn’t do the task because I thought I would feel too uncomfortable doing it’). It is thus worthwhile raising this attitude as a potential obstacle to homework completion even though your client doesn’t mention it. This is what I did with Norman.

Windy: Now, Norman, it is often useful in therapy to troubleshoot any reasons why you might not do what you have agreed to do for homework. Can you think of any reason why you might not do yours? Norman: No. I’m pretty sure that I will do it. Windy: But what if you begin to feel very uncomfortable in the moments before you have decided to speak up? Norman: Good point. If that happened I might well duck out of doing it. Windy: What do you think you would need to tell yourself to speak up even though you were feeling uncomfortable? Norman: That I can speak up even though I am feeling very uncomfortable and that if I do speak up the discomfort will probably subside. Windy: Would that work? Norman: Yes, it would. Windy: So why not imagine yourself feeling very uncomfortable in the seminar situation and show yourself that you can speak up anyway? Norman: That’s a good idea. 168

Experienced general practitioners know that one way of increasing the chances that patients will follow medical advice is to provide them with a written summary of that advice. There are several reasons why a patient may not remember medical advice. First, they may simply forget the advice. Second, the advice may be too complex to be processed properly at the time. Third, the patient may be anxious during the medical consultation and this anxiety may affect their cognitive functioning during and after that consultation. The same factors may operate during the psychotherapeutic interview, and having your client write down the homework assignment or providing them with a written summary of the assignment will increase the chances that they will carry out the assignment. I prefer the former strategy as it puts the onus of responsibility on the client to keep a note of the homework assignment. Some REBT therapists keep a supply of ‘no carbon required’ (NCR) paper on which they write or have their clients write down the homework assignment. NCR paper provides an automatic copy for the therapist to keep in their files to be retrieved at the beginning of the next session, when the therapist will check the client’s assignment (see next chapter). What information should be put on the written record? My practice is to have my client record the following information:

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Encourage your client to keep a written note of their homework assignment and relevant details

1. the nature of the assignment; 2. the purpose of the assignment; 3. how often the client will carry out the assignment; 4. where the client will carry out the assignment; 5. when the client will carry out the assignment; 6. possible obstacles to carrying out the assignment; 7. how these obstacles can be overcome. The above seven sections can be completed by the client at the end of the therapy session in which the homework task has been negotiated. The following three sections are to be completed by the client between therapy sessions: 8. what the client actually did; 9. actual obstacles to carrying out the assignment; 10. what the client actually learnt from carrying out the assignment.

Here is how Norman completed the first seven sections of the homework form at the end of the therapy session in which the assignment was negotiated. 1. The nature of the assignment I will speak up in class while showing myself that I don’t need to be certain that I won’t say anything stupid and that I can accept myself as a fallible human being if I do. 2. The purpose of the assignment Doing this will help me to be able to speak up in class whenever I want to say something, without feeling anxious. 169

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3. How often the client will carry out the assignment Three times. 4. Where the client will carry out the assignment (a) Monday seminar at 3 p.m.; (b) Wednesday seminar at noon; (c) Friday seminar at 10 a.m. 5. When the client will carry out the assignment During the first 20 minutes of each seminar. 6. Possible obstacles to carrying out the assignment Feeling very uncomfortable. 7. How these obstacles can be overcome I can show myself that I can speak up even though I am feeling very uncomfortable and that if I do speak up the discomfort will probably subside.

Rehearse the homework assignment in the therapy room It is often a good idea to rehearse the assignment in the therapy session if this is practicable. If not, you can use imagery rehearsal as a plausible substitute. Rehearsing your client’s homework assignment in the session serves both to increase their sense that they will be able to do the assignment in reality and to identify potential obstacles to homework completion that haven’t been identified through verbal ­discussion of this issue (see below).

Windy: Let’s rehearse the assignment briefly. OK? Norman: OK. Windy: Shall I play your tutor and perhaps one other student and we can imagine that there are other students present too? Your task is to speak up while rehearsing practising the two flexible and non-­extreme attitudes that we discussed. OK? Norman: Fine. Windy (as tutor): So this week we are discussing the role of Catholicism in Evelyn Waugh’s novel Brideshead Revisited . Who would like to kick off? [I first discovered that this was to be the topic for one of Norman’s forthcoming seminars.] Windy (as student): I think that Waugh shows his deep ambivalence about Catholicism in this novel because several of the characters are at one time scornful of it and at another time drawn towards it. Norman: I would agree with that. For example, who would have thought that Sebastian would have ended up as he did, as a kind of unpaid caretaker in a religious order? And his father ended

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Windy (as therapist): How did that go? Norman: I did feel a bit anxious, but that went as I got into my stride. Windy: Do you think this will help you to speak up in the seminar? Norman: Well, I think I’ll be more uncomfortable then, but I’m sure now that I’ll be able to do it.

Use the principle of rewards and penalties to encourage your client to do the homework assignment Sometimes it is helpful to suggest to your client that they can use the principle of rewards and penalties to encourage themself to do their homework assignment. Basically, this involves your client rewarding themself when they do the assignment and penalising (but not condemning) themself if they fail to do it. This principle can be applied by your client particularly when they may not do the assignment owing to an attitude of unbearability, as in the following example.

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his life by making the sign of the cross, even though he spent most of his life being openly scornful of Catholicism. . .

Windy: So you still think that you might not do the assignment if you experience a lot of discomfort. Is that right? Norman: I think so. Windy: If that happens you can use the principle of rewards and penalties as an added incentive. Here is how it works. What do you like doing every day that you would be very reluctant to give up? Norman: Reading the newspaper. Windy: And what do you really dislike doing? Norman: Cleaning the oven. Windy: OK. If you speak up in class you can the read the newspaper and you won’t have to clean the oven. However, if you don’t speak up then you have to clean the oven and no reading the newspaper. Agreed? Norman: Wow, that’s tough. Windy: That’s right. Tough measures for tough problems. Norman: OK. I doubt whether I’ll need to use this principle, but I’ll do it if I need what you call an added incentive. [If your client is going to use the principle of rewards and penalties then have them write this agreement on their homework form.]

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XX Monitor your skills at negotiating homework assignments I strongly encourage you to monitor your skills at negotiating homework assignments with the purpose of improving these skills. I suggest that you do the following:

Record your therapy sessions routinely and use the scale presented in Appendix I to evaluate your performance. Before you do so, please note that very few therapists will score highly on all of the scale’s items. Indeed, some items will not be relevant and there is an opportunity to indicate this on the scale. However, if you do answer ‘No’ to any item (as opposed to ‘Not Appropriate’) then write down what you would have done differently given hindsight and what you would have needed to change in order to have answered ‘Yes’.

As I have suggested throughout this book, take any enduring problems in negotiating homework assignments to your REBT supervisor or trainer. Having negotiated a homework assignment with your client, it is vital that you review it with them at the following session. Reviewing homework assignments is, therefore, the focus of the following chapter.

Reviewing homework assignments In this chapter, I will discuss the issues that arise when you come to review your client’s homework. To give you an idea of the important role that reviewing homework assignments plays in the REBT ­therapeutic process, consider the following view of the structure of REBT sessions put forward by ­Raymond DiGiuseppe (personal communication), the Director of Professional Education at the Albert Ellis Institute in New York:

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◀   C HA P TE R SI X TEEN  ▶

▪▪ Review Homework ▪▪ Carry Out Session Work ▪▪ Negotiate Homework Reviewing homework when therapy is underway, then, is often the first therapeutic task that you have to perform in a session as an REBT therapist and has a decided bearing on the rest of that session. Let me begin the discussion by outlining the most central principle of reviewing homework.

XX Put reviewing your client’s homework assignment on the session agenda Reviewing your client’s homework conveys to them two things. First, it shows them that you consider homework assignments to be an integral part of the therapeutic process. If you, as a client, had agreed to carry out a homework assignment and had actually done so, how would you respond if your therapist did not ask for a report on what you did and what you learnt from doing the assignment? My guess is that you would not be pleased. Being human, you would also be less likely to carry out future homework assignments than you would be if your therapist had reviewed the homework with you. For that is what I have found as an REBT therapist and supervisor: clients are more likely to do homework assignments when their therapists initiate regular reviews of their previous assignments than when their therapists do not do so. Consequently, the first and perhaps the most important principle of reviewing your client’s homework assignments is actually to review them! The second thing that you convey to your client when you review their homework is that you are genuinely interested in their therapeutic progress. Earlier in the process of REBT, you will have helped your client to see that homework assignments are an important vehicle for stimulating therapeutic progress by helping them to deepen their conviction in their flexible and non-­extreme attitudes. In other words, doing homework assignments helps your client to go from intellectual to emotional insight. Asking Fundamentals of Rational Emotive Behaviour Therapy: A Training Handbook, Third Edition. Windy Dryden. © 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.

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your  client about their homework assignments shows that you are taking a regular interest in their ­progress on this issue. If you fail to review their assignments, you may convey the opposite: that you are ­indifferent to their therapeutic progress.

XX When is it best to review homework assignments? Having put reviewing homework assignments on the therapeutic agenda, when is the best time for you to initiate such a review? In my opinion, the best time to review your client’s homework assignments is at the beginning of the next therapy session. If you set a formal, structured agenda for each therapy session with your client, as many cognitive therapists do (see Beck, 2021), you will put the item ‘previous homework’ on the agenda for every session. You will also want to suggest placing this item early on the agenda. The reason for this is that what your client did or did not do for homework and what they learnt or did not learn from doing it will have an important influence on the content of the current session. On the other hand, if your practice is not to set a formal agenda at the beginning of every session, you will still want to initiate the homework review early in the session. Indeed, some REBT therapists routinely begin each therapy session with an enquiry about their client’s previous week’s homework. For example, Ed Garcia used to have a cassette tape in the Albert Ellis Institute’s professional tape library which begins with him asking his client, ‘What did you do for homework?’ There are, of course, exceptions to this principle. For example, if your client comes into the therapy session in a very agitated or even suicidal state, we hope that you would deal with this crisis rather than attempt to review their last homework task! Here, as elsewhere, it is important to practise REBT in a humane, flexible manner.

XX Important issues to consider when reviewing homework assignments In the following sections, I will outline and discuss several points that you need to consider as you review your client’s homework assignment. When your client states that they did the homework assignment, check whether or not it was done as negotiated When your client reports that they carried out the homework assignment, the first point to check when you review the homework assignment is whether or not they did it as negotiated. It may well happen that your client changed the nature of the assignment and in doing so lessened the therapeutic potency of the assignment. You will recall from Chapter 15 that the homework assignment I negotiated with Norman was as follows: ‘I will speak up in three different seminars while showing myself that I don’t need to be certain that I won’t say something stupid before I speak and that if I do say something stupid I can still accept myself as a fallible human being even if others laugh at me.’

There are a variety of ways in which Norman could have modified the assignment. Here is a ­selection of the large number of ways in which Norman might have changed the nature of his homework assignment:

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▪▪ He could have spoken up on three separate occasions, but without rehearsing the flexible and non-­extreme attitudes he was committed to develop. ▪▪ He could have spoken up on three separate occasions while changing his distorted inferences or other unrealistic thoughts rather than rehearsing the flexible/non-­extreme attitudes he wanted to develop. For example, while speaking up he might have told himself that there was little chance of him saying anything stupid or, if he did, that people would be on his side rather than against him. ▪▪ He could have spoken up on three separate occasions while thinking positive, Pollyannaish thoughts such as: ‘Every time I speak up I’m getting better and better’ or defensive thoughts such as: ‘It doesn’t matter if I say something stupid’ or: ‘It doesn’t matter if the people in the seminar group laugh at me if I do something stupid.’

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▪▪ Norman could have done the assignment as agreed, but only on one or two occasions rather than the three we negotiated.

One common way in which your client may change the nature of their negotiated homework a­ ssignment is when they do not face the critical aspect of the situation that they have agreed to face. In REBT parlance, they have not faced the adversity at A. For example, let’s suppose that your client has a fear of being rejected by women when they ask them for a date. In the session you work carefully to help the person to identify and examine their attitudes and to change the rigid/extreme attitude that underpins their anxiety to a flexible/non-­extreme attitude that would lead them to experience healthy concern. Following on from this work you negotiate with the person an assignment which involves them rehearsing their flexible/non-­extreme attitude in the face of actual rejection by a woman. You stress to the client that the important aspect of this assignment is not so much asking women for a date, but being rejected by them. Because the client is afraid of rejection, it is important that they face rejection. At the next session, your client is pleased with the results of their homework. They asked a woman for a date, she accepted their invitation, they spent an enjoyable evening together and they have begun to date regularly. The important point to note from a therapeutic point of view is that the client has not faced the adversity at A that they agreed to face. As I will show you below, it is important that you help your client to see that whatever the outcome of their pleasant evening with the aforementioned woman and the fact that they have begun to date regularly, they have not confronted the source of their problem. They have not been rejected and rehearsed their developing flexible/non-­extreme attitude in the face of such rejection. How do you respond when it becomes clear that your client has changed the nature of their homework? I suggest that you do the following: ▪▪ Step 1: Encourage your client by saying that you were pleased that they did the assignment. ▪▪ Step 2: Explain how, in your opinion, they changed the assignment and remind them of the exact nature of the task as it was negotiated by the two of you in the previous session. In doing so, if indicated, remind your client of the purpose of the assignment which suggested its precise form. ▪▪ Step 3: If your client made a genuine mistake in changing the nature of the assignment, invite them to redo the assignment, but this time as it was previously negotiated. If they agree, ensure that they keep a written reminder of the assignment and ask them to guard against making further changes to it. Don’t forget to review the assignment in the following session. If they don’t agree to do the assignment, explore and deal with their reluctance.

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▪▪ Step 4: If it appears that the change that your client made to the assignment was motivated by the presence of an implicit rigid/extreme attitude, identify and deal with this attitude and again invite your client to redo the assignment as it was previously negotiated, urging them once again to guard against making further changes to the assignment. Alternatively, modify the assignment in a way that takes into account the newly discovered obstacle. Here is an example of how to put this into practice.

Windy: Let’s begin by reviewing your homework. How did it go? Norman: It went fairly well. I managed to speak up on two occasions. Windy: I’m pleased to hear that. Did you practise your flexible/non-­extreme attitudes at the same time? [See Step 1 above.] Norman: Yes, I made sure I did that. Windy: Good. I’ll check what you learnt from doing the homework in a moment. But, first, are you aware that you didn’t quite do all the homework? [See Step 2 above.] Norman: You mean that I didn’t speak up on three occasions? Windy: Yes. It’s important for me to understand what happened on the occasion that you didn’t speak up. Can you help me to understand that? Norman: Well, it was at the Friday morning seminar. I remember feeling quite uncomfortable. . . but er. . . I guess I thought that as I’d done quite well I would give myself a break and not speak up on that day. Windy: I see. You said that you were feeling quite uncomfortable. What exactly was the nature of that feeling? [Here, I am seeking to clarify the client’s C (see Chapter 5). My hunch is that the client did not do the third part of his assignment because he held a rigid/extreme attitude at the time and this led to avoidance – see Step 4.] Norman: I was anxious. . . [I then proceeded to discover that Norman was anxious about saying something stupid in front of a female student whom he found attractive and who rarely attended seminars. I then identified and challenged Norman’s new rigid attitude  – ‘I must speak well in front of Joanna’  – and we negotiated a new homework assignment where he would seek out Joanna and have an intellectual discussion with her while rehearsing his new flexible attitude: ‘I’d like to speak well in front of Joanna, but I don’t have to do so.’ The second assignment that I negotiated with Norman concerned asking Joanna to attend the next seminar and, if she did, he would do the third part of his original homework task. I suggested that Norman ask Joanna to attend the next seminar because, left to her own devices, Joanna might not attend another seminar for a while.]

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The next step in the homework-­reviewing process concerns asking your client what they learnt from doing the homework. If your client learnt what you hoped they would learn, acknowledge that they did well and move on. If your client did not learn what you hoped they would learn, then you need to address this issue. Let me show you how I dealt with this latter situation with Norman.

Windy: So, Norman, you managed to speak up on the three occasions as we agreed and you were also able to practise strengthening your flexible and non-­extreme attitudes. Is that right? Norman: Yes, that’s right. Windy: Good. Now, what did you learn from doing the assignment? Norman: I learnt that it is very unlikely that I will say something stupid in a seminar setting.

Reviewing homework assignments

Review what your client learnt from doing the homework assignment

Windy: Did you learn anything else? Norman: No, that’s about it. [The purpose of the homework assignment was to help Norman address his anxiety about speaking up in class. The way Norman and I chose to do this was to have him examine his attitudes towards not being certain that he would not say anything stupid before he spoke and how others viewed him, and to have him rehearse his flexible and non-­extreme attitudes towards these adversities while speaking up. Ideally, what I would have liked Norman to have learnt was that he didn’t need to be certain before he spoke and that if others laughed at him if he did say something stupid then he could accept himself as a fallible human being in this situation. However, he did not mention either of these two flexible/non-­extreme attitudes in what he learnt. Rather, he said that he learnt that it was now unlikely that he would say something stupid in class. While this is an important learning, it is based on an inferential change which in REBT theory is considered to lead to less enduring results than attitude change (see Chapter 2). Consequently, my task is to explain this to Norman and encourage him to focus on making a change in attitude while not undermining what for him was likely to be a significant piece of learning.] Windy: I think the fact that you learnt that it is unlikely that you will say something stupid in class is important for you, and by saying what I am about to say I do not mean to detract from this. OK? Norman: OK. Windy: Good. Now, when you focused on the idea that you were unlikely to say something stupid, how did this help you? Norman: It got rid of the anxiety and helped me to speak up. Windy: But how do you know for sure that you won’t say something stupid? Norman: I guess I don’t.

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Windy: Right. And let’s suppose that you do say something stupid and people laugh at you, will the thought that you are unlikely to say something stupid help you to deal productively with that situation? Norman: No, it won’t. Windy: Now, again, learning that you are unlikely to say something stupid in class is important, and note that you did speak up without having a guarantee that you wouldn’t say something stupid. Norman: Right, but as we talk about it, I can see that I wasn’t really telling myself that it was unlikely that I would say something stupid. I was telling myself that I definitely wouldn’t say something stupid. Windy: I see. Now, that means that if you are to speak up without such guarantees and if you are to cope with people laughing at you then it would be really useful if you could speak up regularly in class and deliberately say something stupid on one or two occasions. Norman: So that I introduce some uncertainty into the situation you mean? Windy: Exactly. And so you can deal with the possibility or even actuality of people laughing at you. Norman: Wow, that’s a tough assignment. Windy: Well, let’s see if we can negotiate something challenging, but not overwhelming. The main thing, though, is for you to learn (a) that you can speak up even when there is the possibility that you may say something stupid and (b) that you can accept yourself unconditionally as a fallible human being when you do say something stupid and there is a chance that people will laugh at you. [Norman and I then proceeded to negotiate an assignment using the guidelines discussed in the previous chapter.]

Capitalise on your client’s success How do you respond when your client has successfully done their homework and has learnt what you hoped they would learn? I recommend that you reinforce them for their achievement and suggest that they build on their success, as I did with Norman.

Windy: So, Norman, you were able to speak up on three separate occasions while rehearsing your flexible and non-­extreme attitudes. And you say that you are beginning to really believe that you don’t need certainty that you won’t say anything stupid before you speak up and that even if you do say something stupid and people laugh at you, you can accept yourself as a fallible human being in the face of ridicule. Is that right? Norman: Yes, that’s right. Windy: How do you feel about what you have achieved and what you are learning?

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Windy: I’m pleased. I think you are doing really well. . . [humorously] Of course that doesn’t mean that you are a more worthwhile person! Norman: Ha, ha, ha. Windy: Seriously though, you are doing well, so let’s talk about how you can capitalise on your success. OK? Norman: OK. Windy: What do you think you can do between now and next week to extend this? Norman: Well, I guess I can undertake to speak up at every seminar. Windy: Good. How about undertaking to speak up at least twice at every seminar you attend?

Reviewing homework assignments

Norman: I feel really good about it.

Norman: [humorously] You’re a real taskmaster, aren’t you? Windy: Does that mean yes or no? Norman: OK, I’ll do it. Windy: Excellent. Let’s make a written note of what you’re going to do and where and when you are going to do it.

Responding to your client’s homework ‘failure’ Let’s suppose that your client has done their homework, but it turned out poorly. When this happens, ­clients often say that they did the assignment, but ‘it didn’t work’. We have put the word ‘failure’ in inverted commas here because although clients regard the assignment as a ‘failure’, there is much to learn from this situation. So, when you encounter this so-­called ‘failure’, remind your client of the ‘no-­lose’ nature of homework assignments and begin to investigate the factors involved. But first ask for a factual account of what happened. Then, once you have identified the factors that accounted for the ‘failure’, help your client to deal with them and endeavour to renegotiate the same or similar assignment. While you are investigating the factors which accounted for your client’s homework ‘failure’, it is useful to keep in mind a number of such factors. Here is an illustrative list of some of the more common reasons for homework ‘failure’. ▪▪ Your client implemented certain, but not all, of the elements of the negotiated assignment. For example, your client may have done the behavioural aspect of the assignment, but did not rehearse the flexible/non-­extreme attitudes in which they wanted to develop conviction, with the result that they experienced the same unhealthy negative emotions associated with the target problem. ▪▪ The assignment was ‘overwhelming, rather than challenging’ for your client at this time. ▪▪ Your client began to do the assignment but stopped doing it because they began to experience discomfort which they believed they could not bear. ▪▪ Your client rehearsed the wrong flexible and/or non-­extreme attitudes during the assignment. ▪▪ Your client practised the correct flexible and non-­extreme attitudes, but did so in an overly weak manner with the result that their unhealthy negative emotions predominated.

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▪▪ Your client began to do the assignment, but forgot what they were to do after they had begun. ▪▪ Your client began the assignment, but gave up because they did not experience immediate benefit from it. ▪▪ Your client began the assignment, but gave up soon after when they realised that they did not know what to do. This happens particularly with written ABC homework assignments. ▪▪ Your client began the assignment, but encountered an adversity which triggered a new undiscovered rigid/extreme attitude which led them to abandon the assignment. Let’s look at how I responded to Norman when he reported a homework ‘failure’.

Windy: Let’s start by considering your homework. How did it go? Norman: Not very well. Windy: I’m sorry to hear that. Tell me what happened. [Here, I begin by asking for a factual account of Norman’s experience with the assignment.] Norman: Well, before the first seminar, I rehearsed the flexible and non-­extreme attitudes that we discussed and was all geared up to speak up. So after about 10 minutes. . . I spoke up, but it didn’t go too well. So I didn’t do it again. Windy: Now, do you remember the concept of the ‘no-­lose’ homework assignment? Norman: I think so. It means that if I do the assignment and it works out, that’s fine. And it is also valuable if I do it and it doesn’t work out well; that’s also valuable because we can discover why. Windy: Good. Now, let’s see if we can discover why in your case. Let me start by asking you what flexible and non-­extreme attitudes you rehearsed before speaking up at the first seminar. [Norman’s report indicated that he rehearsed the correct flexible and non-­extreme attitudes and did so with sufficient force.] Windy: Well, that seems fine. Now, let’s look closely at what happened when you spoke up at the first seminar. Norman: Well, there was a gap in the conversation so I went over the flexible and non-­extreme attitudes again and took the plunge and spoke up. Windy: And what happened? Norman: Well, I wasn’t too anxious while I was speaking. But when I stopped I got a bit depressed. Windy: What were you most depressed about? [Here, I am attempting to identify Norman’s adversity. It transpired that Norman was depressed about not saying something particularly noteworthy. His rigid/extreme attitude was: ‘When I speak up in class, I must say something noteworthy and if I don’t then I am something of a failure.’ I then helped Norman to examine this rigid/extreme attitude and his flexible/non-­ extreme attitude alternative and to change the former to the latter.]

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Norman: Yes, I can. That’s really helpful. I can now really see what you meant by the ‘no-­lose’ homework assignment. Windy: That’s really good. Now, let me suggest that you do the same homework between now and next week, but this time how about rehearsing the new flexible/non-­extreme attitude as well, namely: ‘I would like to say something noteworthy every time I speak up in class, but I don’t have to do so. If I don’t, I’m not a failure. Rather, I am a fallible human being who says noteworthy and mundane things at times’? Norman: That’s a good idea. [I then take Norman through an imagery assignment to give him some practice at the new flexible/non-­extreme attitude after which we both make a written note of his new assignment.]

Reviewing homework assignments

Windy: So, Norman, can you now see why you got depressed about what you said and why you didn’t speak up in the subsequent two seminars?

Dealing with the situation when your client has not done the homework assignment Despite the fact that you may have taken the utmost care in negotiating a homework assignment with your client and instituted all the safeguards that we discussed in Chapter 15, your client may still not carry it out. When this happens, I suggest that you follow a procedure similar to that which I discussed in the previous section; that is, ask your client for a factual account of the situation where they contracted to do the assignment but didn’t do it, remind them of the ‘no-­lose’ concept of homework assignments, identify and deal with the factors that accounted for them not doing the assignment and then renegotiate the same or similar assignment. As you investigate the aforementioned factors, be particularly aware of the fact that you may have failed to institute one or more of the safeguards reviewed in the previous chapter. If this is the case, and your failure to do so accounts for your client not carrying out the assignment, then take responsibility for this omission, disclose this to your client, institute the safeguard and renegotiate the assignment. On the other hand, if the reason why your client did not do the assignment can be attributed to a factor in the client that you could not have foreseen, help them to deal with it and again renegotiate the same or similar assignment. In investigating the reason why Norman did not carry out his homework, it transpired that he did not do so because he believed that he had to feel comfortable before speaking up.

Team up with a trainee colleague, play the role of therapist and have them play Norman and see if you can help your ‘client’ over the obstacle and then renegotiate the same homework assignment. Record the interchange and play the recording to your REBT trainer or supervisor for feedback.

Appendix II contains a form that we recommend you use with your clients when they consistently fail to initiate negotiated homework assignments. We suggest that you use this form in training as well.

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Again, pair up with a trainee colleague and have them play the role of a ‘client’ who doesn’t do homework assignments for each of the reasons shown on the form in Appendix II and gain practice at helping your ‘client’ over the obstacle. Record the interchanges and once again seek feedback from your REBT trainer or supervisor.

In this book, I have concentrated on key aspects of REBT theory and practice. When dealing with the latter, I have shown you how to assess common client problems, examine rigid/extreme attitudes (that underpin these problems) and flexible/non-­extreme attitudes (that provide the foundation for a healthy solution to these problems) and encourage your clients to act on their emerging flexible/non-­extreme attitudes. As this book’s title makes clear, the book aims to teach you the fundamentals of REBT and as such I have deliberately omitted many of its elaborations. Having said that, I would not be happy that I have taught you the fundamentals of REBT without showing you how to respond constructively to the many doubts, reservations and objections that your clients may have to salient aspects of REBT theory and practice. As many of these are based on misconceptions of REBT, I have chosen to title the next chapter ‘Dealing with your clients’ misconceptions of REBT theory and practice’.

Dealing with your clients’ misconceptions of REBT theory and practice As I noted at the end of the last chapter, you may find that your clients have a number of doubts, reservations and objections (DROs) to the theory and practice of REBT. This is to be expected and you need to discuss these openly with them when their DROs are likely to interfere with the therapeutic process and with their progress. Indeed, in Chapter 13, I discussed some of the DROs clients have about developing flexible and non-­extreme attitudes and letting go of their rigid and extreme attitudes and how to respond to these DROs. In this chapter, I will discuss other frequently expressed DROs clients have with respect to REBT theory and practice1 and explain why they are based on misconceptions of this approach. In presenting these DROs I will put them in the form of typical questions that clients ask. While my answers are each presented in the form of an extended didactic presentation, please note that in clinical practice I engage my clients in a dialogue based on the content to be found in each response. I recommend that when you deal with your clients’ misconceptions about key aspects of the theory and practice of REBT you engage them in such a dialogue and not talk at them. However, if you are going to use didactic explanations make sure that you check that your client understands the points that you are making and that you discuss their reactions to these points with them. Please note that in responding to these misconceptions I will write in the singular.

Dealing with your clients’ misconceptions of rebt theory and practice

◀  CHAPTER SE V ENTEEN  ▶

Question 1: REBT states that events don’t cause emotions. I can see that this is the case when negative events are mild or moderate, but don’t very negative events like being raped or losing a loved one cause disturbed emotions? Answer: Your question directly impinges on the distinction that REBT makes between healthy negative emotions (HNEs) and unhealthy negative emotions (UNEs) (see Chapter 4). Let me take the example of rape that you mentioned. There is no doubt that being raped is a tragic event for both women and men. As such, it is healthy for the person who has been raped to experience a lot of distress. REBT conceptualises this distress as healthy even though it is intense. Other approaches to therapy have as

  Non-­REBT therapists have similar DROs about REBT as well.

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Fundamentals of Rational Emotive Behaviour Therapy: A Training Handbook, Third Edition. Windy Dryden. © 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.

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their goal the reduction of the intensity of negative emotions. They take this position because they do not keenly differentiate between HNEs (distress) and UNEs (disturbance). Now, REBT keenly distinguishes between healthy distress and unhealthy disturbance. Healthy distress stems from your flexible and non-­extreme attitudes towards a negative activating event, while disturbance stems from your rigid and non-­extreme attitudes towards the same event. I now have to introduce you to one of the complexities of REBT theory, and as I do you will see that REBT is not always as simple as ABC! REBT theory holds that the intensity of your healthy distress increases in proportion to the negativity of the event that you face and the strength of your flexible and non-­extreme attitudes. Now, when a ­person has been raped, their intense distress stems from their strongly held flexible and non-­extreme attitudes towards this very negative A. As virtually everyone who has been raped will have strongly held flexible and non-­extreme attitudes towards this event, we could almost say that being raped ‘causes’ intense healthy distress. Now let me introduce rigid and extreme attitudes into the picture. REBT theory argues that you, being human, easily transmute your flexible and non-­extreme attitudes into rigid and extreme attitudes, especially when the events you encounter are very negative. However, and this is a crucial and controversial point, the specific principle of emotional responsibility states that you are largely responsible for your emotional disturbance because you are responsible for transmuting your flexible and non-­extreme attitudes into rigid and extreme attitudes. You and others retain this responsibility even when you and they encounter tragic adversities such as rape. So REBT theory holds that when a ­person has been raped, they are responsible for transmuting their strongly held flexible and non-­ extreme attitudes into rigid and extreme attitudes, even though it is very understandable that they should do this. Actually, if we look at the typical rigid and extreme attitudes that people have towards being raped, we will see that these attitudes are not an integral part of the rape experience, but reflect what people bring to the experience. Examples of rigid and extreme attitudes are: ▪▪ ‘I absolutely should have stopped this from happening.’ ▪▪ ‘This has completely ruined my life.’ ▪▪ ‘Being raped means that I am a worthless person.’ While it is understandable that people who have been raped should think this way, this does not detract from the fact that they are responsible for bringing these rigid and extreme attitudes to the experience. It is for this reason that REBT theory holds that very negative actual As do not ‘cause’ emotional disturbance. This is actually an optimistic position. If highly aversive events did cause emotional disturbance, then you would have a much harder time overcoming your disturbed feelings than you do when we make the assumption that these feelings stem largely from your rigid and extreme attitudes. One more point. Some REBT therapists distinguish between disturbed emotions that are experienced when a very negative event occurs and disturbed feelings that persist well after the event has happened. These therapists would argue that being raped does ‘cause’ disturbed feelings when the event occurs and for a short period after it has happened, but if the person’s disturbed feelings persist well after the event then the person who has been raped is responsible for the perpetuation of their disturbances via the creation and perpetuation of their rigid and extreme attitudes. These therapists argue that time-­limited irrationalities in response to very negative adversities are not unhealthy reactions, but the perpetuation of these irrationalities is unhealthy. Thus, for these REBT therapists a very negative adversity like rape does ‘cause’ emotional disturbance in the short term, but not in the long term.

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Answer: You have a major criticism of the principle of emotional responsibility which is so central to REBT theory. As I showed in my previous answer, when someone is raped, it is possible to argue that this very negative actual A ‘causes’ the intense healthy distress that the person almost invariably experiences. However, if they experience emotional disturbance, particularly long after the event happened, REBT theory holds that they are responsible for their disturbed feelings through the rigid and extreme attitudes that they bring to the event. However, there is a world of difference between being responsible for one’s disturbance and being blamed for having these feelings. The concept of responsibility in this situation means that the person largely disturbs themselves about the event because of the rigid and extreme attitudes they bring to that event. The concept of blame here means that someone believes that the person absolutely should not experience such disturbed feelings and is a bad person for having these feelings. This is obviously nonsense for two reasons. First, if the person disturbs themself about being raped then all the conditions are in place for them to do so. In other words, if they hold a set of rigid and extreme attitudes towards the event, then empirically they should disturb themself about it. It is obviously inconsistent with reality for someone to demand that the person absolutely should not disturb themself in this way. Second, even if we say that it is bad for the person to have disturbed themself, there is no reason to conclude that they are a bad person for doing so. There is, of course, evidence that they are a fallible human being who understandably holds a set of rigid and extreme attitudes towards a tragic event. Rather than being blamed for their disturbance, they should preferably be helped to overcome it. The concept of blame in this situation also tends to mean, at least in some people’s eyes, that the person is responsible for being raped and therefore should be blamed for it happening. This is again nonsense. Let me be quite clear about this. Rape inevitably involves coercion. Even if the person is responsible for ‘leading the other person on’, that other person is responsible for committing the rape. Nothing, including whether the person who has been raped experiences distressing or disturbed feelings, absolves that other person from this responsibility. So, if a person has been raped nothing that they did or failed to do detracts from the fact that the person committing the rape is solely responsible for their actions. As such, the person who has been raped cannot be held responsible for being raped. They can be held responsible for ‘leading the other person on’ if this can be shown to be the case; but, I repeat, they cannot be held responsible for being raped. Thus, the principle of emotional responsibility means in this situation that the person who has been raped is responsible for their disturbed feelings only. They are not to be blamed for this, nor are they to be held responsible for being raped no matter how they behaved in the situation.

Dealing with your clients’ misconceptions of rebt theory and practice

Question 2: I’m worried about the principle of emotional responsibility. Doesn’t it lead to blaming the victim?

Question 3: But if you say that I disturb myself about your bad behaviour, for example, won’t that lead you to say that my response has got nothing to do with your behaviour and isn’t that a cop-­out on your behalf? Answer: The cop-­out criticism of emotional responsibility can be stated thus. If a person is largely responsible for their own disturbed feelings, then if you act nastily towards them all you have to say is that because they largely disturb themself about your bad behaviour then their feelings have nothing to do with you. In my answer to question 2, I pointed out that a person committing a rape is responsible for carrying out that rape regardless of how the person who has been raped feels and regardless of any so-­called mitigating circumstances. Now, if I act nastily towards you I am responsible for my behaviour regardless of how you feel about my behaviour. If my behaviour is nasty, then I cannot be absolved of responsibility for my action just because you are largely responsible for your making yourself disturbed about the way I have treated you. Don’t forget, if my behaviour is that bad, it is healthy for you to hold strongly a set of flexible and non-­extreme attitudes towards it, and whereas I cannot be held responsible

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for your disturbance, I can be said to be responsible for your distress. Thus, I cannot ‘cop out’ of my responsibility for my own behaviour, nor for ‘distressing’ you. The cop-­out criticism is also made of the REBT position on guilt. As I have shown in my book Coping with Guilt (Dryden,  2013b), guilt is an unhealthy emotion that stems from a set of rigid and self-­ devaluation attitudes towards breaking one’s moral code, for example. The healthy alternative to guilt is remorse, which stems from a set of flexible and unconditional self-­acceptance attitudes towards a moral code violation. The important point to note about remorse is that it does not absolve the person from taking responsibility for breaking their moral code. It does not, in short, encourage the person to ‘cop out’ of assuming responsibility for what they did. Now, this is apparently a difficult point for people to grasp. For example, Marje Proops, the late famous agony aunt, claimed to have read my original book on guilt (Dryden, 1994) – in which I continually reiterate the non-­‘cop-­out’ position of remorse – but said in response to a letter from a reader who sought help to stop feeling guilty about sleeping with her best friend’s husband that the reader SHOULD feel guilty. Proops feared that remorse and even guilt (which she clearly failed to differentiate) would provide the person with a ‘cop-­out’ or an excuse for continuing to act immorally. The truth is, however, very different. Remorse is based on the flexible and non-­extreme attitude ‘I wish I hadn’t broken my moral code, but there is no reason why I absolutely should not have broken it. I broke it because of what I was telling myself at the time. Now let me accept myself and think how I can learn from my past behaviour so that I can act morally in the future.’ As you see, in remorse the person takes responsibility for their behaviour and is motivated to act better next time by their flexible and non-­extreme attitude, which also enables them to learn from their moral code violation. By contrast, guilt is based on a rigid and extreme attitude which will either encourage the person to deny responsibility for their past action or interfere with their attempt to learn from it. So, far from encouraging the person to ‘cop out’ of their responsibility, the principle of emotional responsibility encourages the person to take responsibility for their actions and for their disturbed guilt feelings. It further encourages the person to examine their guilt-­producing rigid and extreme attitudes and to adopt a remorse-­invoking flexible and non-­extreme attitude so that they can learn from their past behaviour, make appropriate amends and take responsibility for their future behaviour. Question 4: You have discussed the ABCs of REBT, but I find this overly simplistic. Isn’t the theory of REBT too simple? Answer: First, let me say in answer to your question that I have presented enough of the theory of REBT to help you get started with its practice. If I presented the full complexity of the ABCs of REBT, then I would run the risk of overwhelming you with too much information too soon. In reality, as Albert Ellis (1994) has argued, the ABCs interact in often complex ways. Let me give you a few examples of this complexity. So far, as you have rightly observed, I have introduced the simple version of the ABCs, where A occurs first and B second to produce a set of emotional and behavioural consequences at C. This is the version of the ABCs that is usually taught to clients. Now let me introduce some complexity into the picture. If a person holds a rigid/extreme attitude towards an event, then they will tend to create further distorted inferences about this A. For example, if you hold the rigid attitude that you must be loved by your partner (unhealthy basic attitude (UB)) and they shout at you (A1) then you will be more likely to think that they don’t love you and are thinking of leaving you (A2) than if you have an alternative flexible and non-­extreme attitude (healthy basic attitude (HB)). So, instead of the usual formula: A → B → C, we have A1 → UB →A2. Second, if a person is already experiencing an unhealthy negative emotion (UNE) then this will lead them to attend to certain aspects in a situation. Thus, if you are already anxious then you are more likely to focus on the threatening aspects of a situation than if you are concerned but not

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Question 5: I get the impression that REBT neglects the past. Am I right? Answer: As I have shown, REBT states that people disturb themselves (C) by the basic attitudes (B) that they hold towards life’s adversities (A). Now, As can be present events, future events or past events. Thus, if a client is disturbed now about certain aspects of their past, then an REBT therapist would certainly deal with this using the ABC framework where A is the past event (or events). What REBT questions, however, is the position that a client’s past has MADE them disturbed now. This, you will recall, is an example of A causes C thinking, to which REBT objects. Now, even if it is assumed temporarily that the client was made disturbed as a child by a past event, or more usually by an ongoing series of events, REBT theory argues that the reason that the person is disturbed now about their past is because in the present they hold a set of rigid and extreme attitudes that they have actively kept alive or perpetuated from the past. Actually, the situation is more complex than this because REBT holds that we are not, as children, made disturbed by events; rather, we bring our tendencies to disturb ourselves to these events. Thus, REBT adheres to a constructivist position even about the origins of psychological disturbance. This means that you construct your disturbance rather than your past bringing it about. Your REBT therapist certainly works with the past, but does so mainly by looking at your presently held rigid and extreme attitudes towards your past. In addition, your therapist can consider your past disturbed feelings about specific or ongoing historical situations and help you to see what rigid and extreme attitudes you were holding then to create those past disturbed feelings. I have also found it useful to make the past present by, for example, encouraging the client to have a two-­chair dialogue with figures from the past to identify, examine and change the client’s present rigid and extreme attitudes towards these figures. This technique has to be used sensitively as it often provokes strong emotion. To summarise, REBT does not ignore a client’s past but works with past material either by encouraging the client to examine currently held rigid and extreme attitudes towards historical events or to examine past rigid and extreme attitudes that the client may have held towards these same events. However, REBT guards against A → C thinking by making it clear that it does not think that past events cause present disturbance.

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anxious. Putting this into a formula, we have C → A. I hope these two examples have given you a flavour of the complexity of the ABCs of REBT and have helped you to see that while in its rudimentary form the ABC model is simple, its full version is neither too simple nor simplistic.

Question 6: Doesn’t the REBT concept of acceptance encourage complacency? Answer: The REBT concept of acceptance certainly gives rise to a lot of confusion in people’s minds. Some, like you, consider that it leads to complacency; others think it means indifference; yet others judge it to mean that we should condone negative events. Actually, it means none of these things. Let me carefully spell out what REBT theory does mean by the term ‘acceptance’. The first point to stress is that acceptance means acknowledging the existence of an event, for example, and that all the conditions were in place for an event to occur. However, it does not mean that it is good that the event happened, nor that there is nothing one can do to rectify the situation. Let’s suppose that I betray your trust. By accepting this event, you would acknowledge that I did in fact betray you and that unfortunately all the conditions were in place for this betrayal to occur: namely, that I had a set of thoughts which led me to act in the way that I did. Accepting my betrayal also means that you actively dislike my betrayal (i.e., you don’t condone the way I treated you), but that you do not condemn me as a person. Furthermore, acceptance certainly does not preclude you from taking constructive action to rectify the situation. Acceptance, in short, is based on a set of flexible and non-­extreme attitudes that lead you to

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feel healthily negative about my behaviour, rather than emotionally disturbed about what I did. The same argument applies to the concept of unconditional self-­acceptance. When I accept myself unconditionally for breaking my moral code, I regard myself as a fallible human being for my wrongdoing. I do not condone my behaviour; rather, I take responsibility for it, strive to understand why I acted in the way that I did, learn from the experience, make appropriate amends and resolve to apply my learning so that, in similar circumstances, I can act morally. So, rather than encouraging complacency, acceptance is the springboard for constructive change. Question 7: Doesn’t REBT neglect my emotions? Answer: The short answer to this question is no. Your question focuses on the meaning of the term ‘rational’, the ‘R’ in REBT. Many people think that the term ‘rational’ means devoid of emotion. They think that the model of psychological health advocated by REBT is epitomised by Mr Spock in Star Trek or the android Data in Star Trek: The Next Generation, who were both seemingly incapable of experiencing human emotion. This is far from the case. The term ‘rational’2 in REBT means, among other things, experiencing healthy emotions – that is, emotions which aid and abet you as you strive to pursue your basic constructive goals and purposes. Your REBT therapist is particularly interested in helping you identify your UNEs about the adversities in your life events as a prelude to identifying your rigid and extreme attitudes which are deemed to underpin these emotions. As a first step in therapy, your therapist helps you to examine and change these rigid and extreme attitudes so that you can think ‘rationally’ about these events and feel healthily negative about them. In addition, unlike other therapists, your REBT therapist encourages you to feel intense HNEs about very negative events. As your REBT therapist keenly differentiates between HNEs and UNEs, a distinction that other therapists tend not to make, they will be able on theoretical grounds to help you feel healthily distressed without feeling emotionally disturbed. On the other hand, your REBT therapist does not believe that emotional catharsis is therapeutic per se, nor will they encourage you to explore the subtle nuances of your emotions. Rather, they will encourage you to acknowledge your feelings, to feel your feelings, but to detect and examine the rigid and extreme attitudes that underlie these feelings when they are unhealthily negative. So whereas REBT therapists certainly do not neglect their clients’ emotions, they do adopt a particular stance towards these emotions as outlined above. Question 8: With its emphasis on techniques, doesn’t REBT neglect the therapeutic relationship? Answer: The famous American psychologist Carl Rogers (1957) wrote a seminal paper on the therapeutic relationship which for many set the standard against which other approaches should be judged. Rogers argued that there were a set of necessary and sufficient ‘core conditions’ that the therapist had to provide, and the client had to perceive the therapist as having provided these conditions for therapeutic change to occur. Two years later Albert Ellis (1959), the founder of REBT, published a reply in which he acknowledged that these conditions were important and frequently desirable, but they were hardly necessary and sufficient. This has been the REBT position ever since. Thus, REBT therapists do not neglect the therapeutic relationship. However, they do not regard the relationship as the sine qua non of therapeutic change. Some REBT therapists regard the development of a good therapeutic relationship as setting the ground for the ‘real therapy’ to take place – that is, the application of REBT techniques. My own position is somewhat different. I regard the application of REBT techniques and so-­called relationship factors as interdependent therapeutic variables. The one set of variables depends for its therapeutic effect on the presence of the other set (Dryden, 2021b). Finally, research has shown that REBT therapists 2

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  See the Introduction for a discussion of why I no longer use the term ‘rational’ in REBT.

Question 9: REBT therapists may not neglect the therapeutic relationship with their clients, but isn’t this relationship unequal? Answer: It depends on what you mean by unequal. Your REBT therapist considers themselves to be equal to you as humans. They are neither more worthy than you, nor vice versa. However, on different aspects of your respective selves, there are likely to be inequalities. You may know more about gardening or be more sociable than your therapist, for example. You are equal in humanity, but unequal in certain areas. Now, the purpose of therapy is to help you to overcome your psychological problems and live more resourcefully. In this area, your REBT therapist claims to know more about the dynamics of emotional problems and facilitating personal change than you, at least from an REBT perspective, and this does constitute an inequality, as do the ones mentioned earlier that are in your favour. REBT therapists openly acknowledge this real inequality, but stress that it needs to be placed in the context of a relationship between two equally fallible human beings (Dryden, 2021b). Question 10: How do you respond to the criticism that REBT therapists brainwash their clients? Answer: First, let me be clear what I mean by brainwashing. Brainwashing is a process where the person to be brainwashed is isolated from their normal environment and from people whom they know, is deprived of food, water and sleep and when judged to be in a susceptible state is provided with information and attitudes which are usually counter to the information and attitudes they would normally hold. Obviously, by this definition REBT therapists do not brainwash their clients. However, I think you mean something more subtle than this. I think you mean that REBT therapists tell their clients what to think without due regard to their current views and press them hard to believe the REBT ‘line’. If this is what you mean, then I would deny that well-­trained, ethical REBT therapists would do this (I cannot speak for untrained individuals who pass themselves off as REBT practitioners). REBT holds that one of the hallmarks of mental health is the ability to think for oneself and to be sceptical of new ideas. It regards gullibility, suggestibility and uncriticalness as breeding grounds for emotional disturbance. So, in presenting REBT principles, skilled REBT therapists elicit both their clients’ understanding of these concepts and their views of these ideas. There usually follows a healthy debate between client and therapist where the therapist aims to correct the client’s misconceptions of these REBT principles in a respectful manner (as I hope I am demonstrating with you now). At no time does the therapist insist that the client must believe the REBT concepts they are being taught. If a therapist does so insist, this is evidence of the therapist’s rigid and extreme attitude, such as: ‘I have to get my client to accept REBT principles and if I fail in this respect this proves that I am a lousy therapist and a less worthy person as a result.’ Also, you will recall from Chapter 13 I stressed that REBT therapists encourage their clients to voice their DROs about REBT and take these seriously. This is almost the antithesis of brainwashing. Now, it is true that REBT therapists do have a definite viewpoint concerning the nature of psychological disturbance and which conditions best facilitate therapeutic change. It is also true that REBT therapists are open with their clients concerning these views and strive to present them as clearly as they can. However, just because REBT therapists teach REBT principles to their clients, it does not follow that they are attempting to brainwash their clients or impose their views on them. My own practice is to make clear that (a) I will be offering a specific approach to therapy based on a particular framework, (b) there are other approaches to therapy that offer different frameworks and

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scored as highly as therapists from other schools on measures of the ‘core conditions’ provided by clients (DiGiuseppe et al., 1993). If REBT therapists are neglecting the therapeutic relationship, their clients don’t seem to think so!

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(c) I am happy to make a referral if it transpires that the client is better served by a different therapeutic approach. I believe that many REBT therapists act similarly with their clients. This, I hope you will agree, is a long way from brainwashing. REBT therapists have preferred therapeutic goals, but are prepared to negotiate and make compromises if it becomes clear that the client is unwilling or unable to work towards philosophic change. I have yet to hear of a brainwasher who is prepared to negotiate and make compromises! Question 11: But don’t REBT therapists tell their clients what to feel and what to do? Answer: My answer to this question is similar to my reply above. REBT therapists keenly discriminate between HNEs and UNEs. Their initial goal is to help clients minimise their disturbance about adversities, while encouraging them to acknowledge, experience and channel their healthy distress about these As. However, your REBT therapist will make clear that you have a choice concerning your feelings and behaviour. Just because REBT theory advocates that you minimise your disturbed feelings, but not your distressed feelings, it does not follow that you have to agree with this view. The same is true of behaviour. Your REBT therapist may well point out to you the self-­defeating nature of your behaviour, but they do not insist that you follow their lead. As with the issue of attitudes, your REBT therapist has preferences concerning how their clients feel and behave in relation to the issue of psychological health and disturbance and they may well articulate these preferences during therapy. After all, your REBT therapist genuinely wants to help their clients live psychologically healthy lives, and they believe that they have a good theory to help their clients do this. However, your REBT therapist respects their clients’ freedom and does not transmute their preferences into musts on this issue, even if this means that a particular client may continue to perpetuate their psychological problems. That person’s REBT therapist will, of course, explore the reasons for this, but will not in the final analysis insist that the client do the healthy thing. Incidentally, in areas not related to the issue of psychological health and disturbance, REBT therapists are quite laissez-faire about their clients’ feelings and behaviour. For example, whether you pursue stamp-­collecting or body building is not the therapist’s concern, assuming that both of these activities are based on preferences and are not harmful to others or to the environment. Question 12: From what you have been saying, it seems to me that REBT therapists prevent clients from finding their own solutions to their problems. Am I right about this? Answer: In answering this question, I need to distinguish between two types of solutions: psychological solutions and practical solutions. In REBT, a psychological solution to your problems in the main involves you identifying, examining and changing your rigid and extreme attitudes to a set of flexible and non-­extreme attitudes, whereas a practical solution involves, among other things, responding behaviourally to negative As in functional ways. In this analysis, achieving a psychological solution facilitates the client applying the practical solution and, therefore, preferably should be achieved first. Now, your REBT therapist assumes that you as the client will not achieve an attitude-­based psychological change on your own. They further assume that they need to help you in active ways to understand what this psychological solution involves and how you can apply it. Once they have helped you to do this then you are generally able to choose the best practical solution to your problem. If not, your REBT therapist will help you to specify different practical solutions to your problem and will encourage you to list the advantages and disadvantages of each course of action and to select and implement the best practical solution. So, in summary, REBT therapists actively encourage their clients to understand and implement REBT-­orientated psychological solutions to their problems and assume that once this has been done then clients will often be able to see for themselves which practical solutions to implement. When the therapist

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Question 13: Isn’t REBT too confrontational? Answer: REBT is basically an active-­directive approach to psychotherapy where your therapist intervenes actively and directs you to the attitudinal core of your problems and helps you to develop a plan to examine your self-­defeating rigid and extreme attitudes which constitute this core. In helping you to examine your rigid and extreme attitudes and corresponding flexible and non-­extreme attitudes (see Chapter 13), the therapist does take the lead in questioning you concerning the empirical, logical and pragmatic nature of both sets of attitudes. The attitude-­examining techniques of the therapist often seem overly confrontational to therapists who advocate less directive counselling methods. It is the contrast between these methods and the active-­directive methods of REBT that lead these therapists to conclude that REBT is TOO confrontational. If your REBT therapist prepares you adequately for their active-­directive methods, particularly their attitude-­examining techniques, then in general you will not consider the therapist to be TOO confrontational, although the observing less directive therapist who does not fully understand what the REBT therapist is trying to do might consider this therapist to be overly confrontational. However, if your REBT therapist fails to give a satisfactory rationale for their behaviour, then they may well be experienced by you as TOO confrontational. Question 14: You say that REBT is a structured therapy, but doesn’t it ‘straitjacket’ clients? Answer: While it is true that REBT is a structured approach to psychotherapy, it is also the case that skilled REBT therapists vary the amount of structure according to what is happening in the session. Thus, at times your REBT therapist may be quite unstructured – for example, when you have started to talk about a newly discovered problem; or they may use session structure rather loosely – for example, in the ending phase when prompting the client to assess a problem using the ABC framework. Of course, at other times your REBT therapist will be quite structured, particularly when helping you to examine your rigid/extreme and flexible/non-­extreme attitudes. Again, if the therapist provides a rationale for the use of a tight structure and the client understands and assents to this, then the client won’t consider that they have been ‘straitjacketed’ by the therapist, although the observer might make such a conclusion.

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does intervene in the practical problem-­solving phase of therapy, it is to help the client weigh up the pros and cons of their own generated solutions and to select the most effective course of action.

Question 15: Isn’t it the case that REBT is only concerned with changing attitudes? Answer: REBT therapists are primarily concerned with helping their clients to pursue their basic goals and purposes. In order to facilitate this process, the therapist encourages you to experience HNEs rather than UNEs about life’s adversities and to act functionally in the face of these negative events. Now, REBT therapists do hold the view that a central way of helping clients to achieve all this is to encourage them to change their rigid/extreme attitudes to corresponding flexible/non-­extreme attitudes, but this is not their sole goal. So, REBT therapists are interested in helping clients to change their attitudes, their feelings, their behaviour, their images, their interpersonal relationships and the aversive events in their lives. As such REBT is a multimodal rather than a unimodal approach to therapy. A similar issue relates to how REBT is often portrayed in therapy-­outcome studies. In some of these studies REBT is deemed to be synonymous with its cognitive restructuring methods rather than with a multimodal approach which also employs emotive, behavioural, imaginal and relationship-­enhancement techniques. As such, psychotherapy researchers have also wrongly concluded that REBT therapists are ONLY interested in helping their clients to change the latter’s attitudes.

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Question 16: REBT relies heavily on verbal interchange between therapist and client. It also advocates concepts that are difficult to grasp. Doesn’t this mean that REBT only works with highly verbal, intelligent clients? Answer: This is a common criticism of REBT and I can understand why you have made it. I have presented REBT to you in its complex sophisticated form. I have used a lot of words and explained its concepts in a way that reflects this complexity. However, skilled REBT therapists can also tailor the way they explain REBT concepts to match the verbal and intellectual capacities of their clients. Rest assured that REBT has been used with clients who are not particularly verbal or intelligent. By all accounts, it works well with these client groups as long as appropriate modifications are made.

Pair up with a trainee colleague and put the above questions to one another so that you can both get used to responding to such criticisms using your own words. Make recordings and review them and work on improving your response to these questions. If you get stuck, ask your REBT trainer or supervisor for guidance.

Using REBT in a single-­session therapy format XX Introduction The vast majority of books on REBT are written on the assumption that a client will stay in therapy for a reasonable length of time so that they can achieve their goals. Theoretically, the more ambitious the client’s goals, the longer they need to be in therapy. Also, therapists tend to assume that the more severe and complex a client’s problems, the longer that person needs to be in therapy. The conventional therapy mindset

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◀   C HAPTER EIGHTEEN  ▶

The majority of this book is based on what might be called the conventional therapy mindset. When holding this mindset, the REBT therapist will make a number of assumptions: ▪▪ Therapy will last longer than one session and often considerably longer. ▪▪ The length of therapy is determined by the client’s diagnosis and problem severity and complexity. For example, the more severe and complex the client’s problems, the longer therapy will be. ▪▪ Assessment will occur before therapy is initiated. This assessment may be done by the therapist themselves (in independent practice) or by a representative of an agency in which the therapist works. The purpose of an agency-­based assessment is to ensure that the client is referred to the most suitable person in the agency. The purpose of assessment done in independent practice is for the practitioner to judge whether or not they can help the person. If they can’t, then a suitable referral is made. ▪▪ After the assessment session, the first session is characterised by one or both of the following activities: a history is taken of the person’s problem and of salient aspects of the person’s life and development; a case formulation is made where links are made between all the client’s problems, highlighting in particular what maintains these problems. ▪▪ Therapy properly gets underway once the therapist has a clear idea of the client’s problems, goals and some of the underlying factors that account for these problems and their maintenance.

Fundamentals of Rational Emotive Behaviour Therapy: A Training Handbook, Third Edition. Windy Dryden. © 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.

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XX Many clients want immediate help All of the above is fine if the client agrees with this way of proceeding. However, as we shall see, many clients want to be helped much quicker than this. Thus, we know that in most therapy agencies across the world, in both public and charitable sectors, the modal1 number of visits clients make is ‘one’, followed by ‘two’, followed by ‘three’, etc. (Hoyt & Talmon, 2014). We don’t know whether this is true in private practice, but when I mentioned this modal figure to one of my REBT colleagues, who has a part-­time practice in the US, he first said that this certainly does not apply to his practice, but then when he checked his records, he recognised that it did. Moreover, 75% of the people he sees come for between one and three sessions! While people have attended one session of therapy probably since the inception of psychotherapy as a formal way of helping people with their psychological problems,2 usually this situation is what Moshe Talmon, the developer of modern-­day single-­session therapy (SST), called ‘unplanned SST’.3 By contrast, based on the modal data referred to above, Talmon (1990) and his colleagues Michael Hoyt and Robert Rosenbaum, who all worked at the Kaiser Permanente clinic in Northern California in the late 1980s, suggested that SST is offered to all clients, and when this happens they refer to it as ‘planned SST’.4 Of course, clients do not have to accept the offer, but Talmon’s point was that as large number of clients seem to want very brief therapy, their needs are no being served when they are only offered a longer intervention. Many people reading this would counter that the reason people only stay for one session of therapy is that they are disappointed with that session and can effectively be viewed as ‘drop-­outs’5 from treatment. However, the evidence is to the contrary. Between 70 and 80% of people who have a single session are satisfied with it and choose not to return for further help at that time (Hoyt & Talmon, 2014). Now, this does not mean that they have reached ‘recovery’ status on the basis of objectives devised by professionals.6 What this means is that from their perspective they require no further help because they were satisfied with the help that they received. Interestingly, from what we know from the SST literature, including from open-­access, ‘walk-­in’ clinics, we as a field have no way of discerning, in advance, which clients will benefit from SST in the sense of needing no further help and which clients will require further help. This is discovered after the single session has been completed, either at that point or after an agreed period where the client goes away to implement what they have learnt from the session and decides whether or not to seek further help. This poses no problem for a therapy agency or independent practitioner offering SST since this is defined as ‘a mutually agreed endeavour based on informed consent where the therapist works with the client to help them to take away what they have come for by the end of the session on the understanding that further help is available if required’. As this definition shows, when working with SST the therapist is working to help the client with their session goal, but is well aware that the client may request more help at the end of the session or after the session. Or the client may not request further help at all.

1   The mode is the most frequently occurring number in a series. Thus, if in a clinic, nine clients have one session each and the tenth has 100 sessions, then the mean number of sessions in this situation is 10.9, while the mode is 1. 2   There are records that Sigmund Freud offered people single-­session consultations while he was on vacation in response to their requests for his therapeutic help. He did not bring this way of working into his regular practice (see Dryden, 2023). 3   Sometimes referred to as ‘SST by default’. 4   Sometimes referred to as ‘SST by design’. 5   I consider a person who has ‘dropped out’ of treatment to be one who has decided for better or worse to seek no further help at that time. As I am about to remark, most of these ‘drop-­outs’ were satisfied with the help they received. 6   It is perfectly all right for someone to seek help when they subjectively decide that they need it, but our field is sceptical when they subjectively decide that they have been helped and seek no further help. Such scepticism is increased when such people have not been deemed to have ‘recovered’ by their scores on the objective measures.

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As a matter of fact, when Albert Ellis first saw a new client, he did not know whether or not the client would come back again.7 As such, Ellis decided to offer the person therapy from moment one rather than doing a full assessment, taking a case history or undertaking a case formulation in that first (and perhaps only) session. From listening to many of Ellis’s first sessions on cassette tape, I discovered that typically Ellis would do the following in his first (and perhaps only) session with the client. He would: ▪▪ Ask the client to nominate a problem that they would like to discuss. ▪▪ Ask the client to provide a specific example of that problem. ▪▪ Assess the example using the ABC framework. ▪▪ Teach the client the B–C connection by using the money model (see Chapter 3). ▪▪ Help the client to examine their main rigid/extreme attitude and work with them to develop their alternative flexible/non-­extreme attitude. ▪▪ Negotiate a behavioural assignment with the client, designed to give them an opportunity to rehearse their new flexible/non-­extreme attitude while facing a relevant adversity. ▪▪ Suggest a reading assignment designed to deepen the client’s understanding of REBT. ▪▪ Suggest that if the client wanted to make another appointment to see him they could do so via the front desk of the Institute.

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XX Albert Ellis’s approach to the first session

Unfortunately, it is not known what the modal number of sessions Ellis had with his clients over the course of his career, but given that he made no attempt to have his clients book another session with him directly, I would suspect that it was one. As we can see from the typical way in which Ellis conducted his first sessions with his clients, REBT is an approach that is quite well suited in general to being offered in an SST format to clients. Before I discuss how this may be done, I want to discuss the important elements of SST that REBT therapists need to know before offering REBT-­based SST.

XX Key principles of the SST mindset We have seen what happens when a therapist or agency approaches the first contact they have with a person seeking help when holding the conventional therapy mindset. If a therapist tries to practise SST while holding a conventional therapy mindset they will be doomed to failure. Thus, it is central to the good practice of SST that the therapist brings a single-­session mindset to this work. When a therapist holds a single-­session mindset they go about things very differently. Thus: ▪▪ They approach the first session as if it is the only time they will see the client, while realising that the client may seek further help. ▪▪ They recognize that the only way of knowing whether a person will benefit from a single session is to offer them a single session and see if they benefit from it.

  Actually, no therapist can know this. While a therapist may be highly skilled, foretelling the future is not part of any therapist’s skillset.

7

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▪▪ They ask the client what the client wants to get from the session and work towards helping them achieve their objective unless they, the therapist, have a good reason not to do so. In which case, they state their reasons clearly and discuss these with the client. Thus, they are clear what they can do in SST and what they can’t do. ▪▪ They actively search for a client’s internal and external resources and help the client to make use of these during the session. ▪▪ They find out what help the client is seeking from therapy and strive to meet these preferences unless, again, they have a good reason not to do so. They recognise in this respect that while most clients will seek emotional problem-­solving from SST, this is not universally the case. Some will want an opportunity to explore and understand an issue, while others want an opportunity to express themselves and get things off their chest. In the latter two cases, the REBT therapist needs to accept that sometimes they will be called upon to help a client without using REBT! A flexible REBT therapist is prepared to do this. ▪▪ If the client is seeking help with an emotional/behavioural problem they discover what the client has done previously to deal with the problem, focusing particularly on what was helpful and what was not helpful. They encourage the future use of the former and the future discontinuation of the latter. ▪▪ They look to co-­create a focus with the client that is informed by the session goal. Once created, the therapist seeks to maintain this focus throughout the session. ▪▪ They will ask the client if they are interested in their views of the client’s problem and what can be done about it rather than assume that they will offer this as a matter of course. When they do offer their perspective they strive to integrate it with other factors listed earlier in this section. ▪▪ They keep in mind the importance of what the client is to take away from the session and are clear that a takeaway is broader than a specific homework assignment. They will also work with a client to help them plan to implement their takeaway(s). ▪▪ They strive to end the session in a way that the client leaves with their morale restored and is clear about how they can access further help in the future if they don’t want to arrange for another session at the end of the single session.

XX The importance of informed consent The concept of informed consent is universally important in the field of counselling and psychotherapy. However, given that SST is a relatively recent development in the field, this concept is even more important. If you had asked upper-­class New Yorkers in the late 1950s how long they expected to be in psychotherapy they would have said ‘years’. However, if you ask people in rural Britain in 2023 the same question you will get a very different answer. It will be a much, much shorter period of time, and a lot of people will say that they expect to go once. Thus, length of therapy is something that therapists should discuss with ‘applicants’8 before contracting with them, at which point they become clients. Applicants for therapeutic services that are made by appointment can only be expected to give their consent for SST if they know about it and, on the basis of this knowledge, they want to apply for

8   An ‘applicant’ is someone who is seeking therapeutic help. They become a client when they have given their informed consent to proceed (Seabury et al., 2011).

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Pair up with a trainee colleague and develop a description of SST that you might put on your own or your agency’s website. Show this to a number of people who are not therapists and get their feedback. Incorporate relevant aspects of their feedback into your website description.

When a person has indicated to the independent practitioner or therapy agency that they wish to make an appointment for SST, they are either sent a contract10 to sign and return or a pre-­session questionnaire11 to complete and return or sometimes both. Even then, when they attend the session, it is wise for the therapist to ask a question such as: ‘From your perspective what is the purpose of the conversation that we are going to have today?’ The client’s answer will tell the therapist if they are ready to proceed with the session or whether further conversation about the purpose of the session is necessary. Just because a person has indicated that they wish to attend SST, it should not be assumed that they know what they are coming for. Not everybody consults the therapist’s or agency’s website or reads information that they are sent about SST. In such cases, the therapist might make a statement such as the following:

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it  specifically. Consequently, it is up to therapists in independent practice and therapy agencies who offer SST to be explicit about what SST is, who it is for and what can be realistically expected from it. This is usually done on the person’s/agency’s website. The main point that needs to be stressed on these websites is that the intention of the therapist is to work with the client to see if they can help the client achieve what they have come for, but if they can’t, further help is available. It should not be forgotten that although this ‘help now, further help later if requested’ principle is at the heart of SST, many people – potential clients and therapists – think that it means that only one session will be offered. Given this, websites should ideally address this issue with clarity and make it explicit that SST is not ‘one-­off therapy’.9

We have found that a large number of our patients can benefit from a single visit here. Of course, if you need more therapy, we can provide it. But I want you to know that I am willing to work with you hard today to help resolve your problem quickly, perhaps even in this single visit, as long as you are ready to start doing whatever is necessary. (Hoyt et al., 1990, pp. 37–38)

Pair up with a trainee colleague and have them play the role of a ‘client’ who has come for SST but has only a sketchy understanding of it. Help them gain a better understanding of it so that they can give their informed consent to proceed. Record the dialogue and when reviewing it with your ‘client’ both of you should suggest ways in which your work could be improved.

9   I am assuming in this chapter that the therapist is working by appointment either in independent practice or in an agency. People who walk into an open-­access SST service are likely to know about the service that they are accessing, although this should not be taken for granted, and an early enquiry from the therapist to the client about what the person hopes to get from their visit is paramount. 10   Some therapists and agencies prefer to have the client’s informed consent signed in writing, while others accept verbal consent. 11   The main purpose of such a questionnaire is to help the person prepare for the session so that they can get the most from it.

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XX The practice of REBT in a single-­session format In this section, I will present an outline of how REBT can be practised within an SST format. It should be viewed as my own suggestions and as certainly not definitive. If you are interested to deepen your knowledge about REBT and SST, I suggest that you consult Dryden (2019, 2020). Send the person relevant pre-­session information and a questionnaire if practicable and if this is part of your or your agency’s practice If you have time between the person making an appointment for SST and the appointment taking place, send them the forms that you wish them to have and, if necessary, complete. These may include further information about SST, an SST-­based contract and a pre-­session questionnaire designed to help the person prepare for the session so that they get the most from it. Some SST therapists prefer not to send out any information pre-­session. At the beginning of the session, ensure that the person understands the nature of SST If the person has a good understanding of SST, get their informed consent to proceed if you have already not received this. If they do not understand the nature of SST, help them to do so. Proceed once they understand and wish to go forward. If they do not, offer them a different mode of help and proceed or refer. As part of this clarification, stress that further help is available to them if needed and that you will discuss this at the end of the session. Ask them what help they are looking for from you While most clients want help with an emotional/behavioural problem, particularly one with which they are stuck, this is not universally the case, and I have found it useful to outline the kinds of help that I can provide, namely: ▪▪ Do you want me to help you to develop greater understanding of the issue you wish to talk about? ▪▪ Do you want me just to listen while you talk about the issue? ▪▪ Do you want me to help you to express your feelings about the issue? ▪▪ Do you want me to help you to solve an emotional or behavioural problem with which you are stuck? ▪▪ Do you want me to help you to make a decision? ▪▪ Do you want me to help you to resolve a dilemma? ▪▪ Do you want another form of help that I have not mentioned? While, in general, I suggest that you offer a person the help they are seeking – which is a major principle of SST – as an REBT therapist you might ask the person a subsidiary question such as: ‘If you got a greater understanding of the issue what would you hope that would lead to?’ Very often, people actually want a solution to a problem and think that this is best achieved by ‘developing a greater understanding of the issue’, ‘just talking about the issue’ or ‘expressing their feelings about the issue’. What I do here is to agree with them that solving the problem is their real goal and offer them some of their requested help before inviting them to hear my take on solving the problem, which will be an REBT one.

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SST is very much goal-­directed, and since we don’t know whether or not a person will return, the emphasis is on their goal for the session, with the following questions: ▪▪ What would you like to take away from the session that you would like to apply in your life? ▪▪ What would you like to achieve by the end of the session that would make it worthwhile that you came today? ▪▪ If later on you were pleased that you came today, what would you have got from the session that would have led you to say that? There are three client-­nominated session goals that REBT therapists will want to respond to rather than accept without comment. I will mention these below and show how I would deal with each. 1. Where the client wants to experience an unhealthy negative emotion (UNE) with less intensity in the face of an adversity

Windy: So what would you like to achieve by the end of our session today? Client: I want to feel less anxious about a job interview I am going to next week.

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Ask them what they want to achieve by the end of the session

Windy: Is anxiety a healthy feeling for you? Client: Not at all. Windy: Since it is not healthy for you, would you be interested in me helping you to have a healthy alternative to anxiety, but one which is still realistic? Client: What would that be? Windy: A healthy non-­anxious concern about the job interview rather than an unhealthy anxiety about it even when the intensity of anxiety is lessened. Client: Yes, I would be very interested in that.

2. Where the client wants to experience the absence of an emotion in the face of an adversity

Windy: So what would you like to achieve by the end of our session today? Client: I have a job interview coming up next week and I want to feel calm about it. Windy: Is getting the job important to you? Client: Very much so. Windy: Since it matters to you, you will have some kind of emotion. Would you be interested in having an emotion that reflects the fact that you care about getting the job, but not one where you care too much?

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Client: Yes, I would. Windy: Well, I call the first a healthy unanxious concern and the second an unhealthy anxiety. Would you be interested in me helping you to feel unanxious concern about the job interview? Client: Yes, that would be good.

3. Where the client wants to change someone else

Windy: So, what would you like to achieve by the end of our session today? Client: I would like some ways that I can change my boss. He is hypercritical and I am getting very anxious about going into work. Windy: Well, in single-­session therapy, it is important that I am honest about what I can do and what I can’t do. Can I be honest with you? Client: OK. Windy: Well, I can’t help you change your boss. Do you know why? Client: Why? Windy: Well, who is in charge of your boss’s behaviour? Client: He is, I guess. Windy: That’s right, and what leads him to be hypercritical? Client: I guess he thinks he is giving productive feedback, but it’s all negative, no praise at all. Windy: So, would it be fair to say that his behaviour is guided by the way he thinks? Client: Yes. Windy: And who is in charge of the way he thinks? Client: He is. Windy: So, together we can’t change the way he thinks and acts, but maybe together we can talk about ways that you might be able to influence him. Would you be interested in that? Client: Definitely. Windy: Two points before we start. The first is that even if we come up with some really good influence strategies, is he free to ignore them? Client: Sadly, yes. Windy: But at least these strategies are in your control. What is not in your control is how your boss responds to them. Correct?

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Windy: The second point is this. You mentioned that you are very anxious about going to work at the moment. Do you think that your anxiety might affect your attempts to influence your boss? Client: Good question. No, I don’t think so; my anxiety is more about me not knowing what to do in the situation. If I had some ways of influencing him, I wouldn’t be anxious. [If the client had said that their anxiety would have interfered with their influence behaviour, I would have offered them the opportunity of dealing with their anxiety first before turning our attention to helping them to develop some mutually agreed influence strategies.]

Going forward in this chapter, I will assume that the client wants help with emotional/behavioural problem-­solving since this the most common form of help people seek from SST. Work with the client’s nominated problem, link this with the client’s session goal and keep the focus on these issues Here, the therapist asks the client what problem they want to focus on and then links with the client’s session goal. The therapist then asks for and works with a relevant example of the client’s nominated problem. If possible, this should be a future example of the problem since this will help the client to apply what they learn in the session to what is predicted will happen imminently. A client can only apply learning to a past example by imaging how they will deal with it if it occurs in the future. It is important that the therapist helps the client to remain focused on their nominated problem and session goal, and, if necessary, the therapist needs to interrupt the client with tact in order to maintain the session’s focus (see Chapter 5).

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Client: Yes.

Enquire what the client has done to try to deal with the problem before This is an important SST strategy and allows you and your client to discover and use strategies that have been to some extent helpful in the past and to discover and not use strategies that have not been helpful. It is important to integrate the former into the REBT work you will be doing later in the session. Enquire about the client’s internal strengths and external resources Doing this is another important SST strategy and helps the client see what strengths and resources they have that they can make use of as they work towards finding a solution to their problem. Here, you can ask the client directly for such information and/or reflect it back as you hear it expressed in their narrative. Pair up with a trainee colleague and take turns to be ‘client’ and therapist. The purpose of this exercise is for the therapist to practise interrupting the ‘client’ in an attempt to help them stay focused. In the therapist role, what did it feel like to interrupt the ‘client’, what did you do well and how could you have done it better? In the client role, give feedback to the therapist concerning what it felt like being interrupted and give feedback concerning what they did well and how they could have improved their interrupting skills.

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Do an ABC assessment of the specif ic example of the client’s problem In doing this, the therapist draws on the knowledge and skills that I have outlined in Chapters 6–9. The main difference is that the therapist does this with a great deal of focus. My practice here is to do the following: ▪▪ Identify the client’s major emotional C, which should be an UNE, and their accompanying unconstructive behavioural C.12 Then identify the client’s HNE alternative and the corresponding constructive behaviour alternative. Link again to the client’s session goal, if relevant. ▪▪ Use the ‘magic question’ technique to identify the client’s adversity at A (see Chapter 7). ▪▪ Use Windy’s review assessment procedure (WRAP) to assess the client’s rigid/extreme and corresponding flexible/non-­extreme attitudes. Use this technique to teach the B–C connection (see Chapter 8). Help the client to examine their rigid/extreme and flexible/non-­extreme attitudes Here I suggest that the therapist use the choice-­based examination method to help the client to examine their rigid and flexible attitudes and the main extreme and non-­extreme attitude with which they most resonate (see Chapter 13). The goal of this is to help them to choose their flexible/non-­extreme attitude to develop moving forward as a means of dealing effectively with the adversity at the heart of their nominated problem. It is again important for the therapist to keep making links between the client’s flexible/ non-­extreme attitude and their session goal. It is also important to help the client to see the connection between their session goal and their problem-­related goal. The former is what they want to achieve by the end of the session, while the latter is what they want to achieve if they are to respond healthily to the adversity at the heart of their problem. It is useful to help them see that the achievement of their session goal is a step in the right direction towards achieving their problem-­related goal. Suggest that the client rehearse the solution in the session Once the client has agreed to go forward with a flexible/non-­extreme attitude, it is important that they rehearse it in some way in the session to see how it ‘fits’. This is also an opportunity to put the attitude in their own words and to come up with a shortened version of it. When the client is rehearsing their attitudinal solution, it is important that they do so while facing a version of their adversity, feeling an HNE and acting constructively. Imagery methods (e.g., rational-­emotive imagery), role-­play and two-­chair dialogue techniques are especially useful here. While the client is rehearsing the solution the therapist should encourage them to factor in salient internal strengths and external resources. Help the client to develop an action plan, agree the f irst steps and deal with potential obstacles When the client has had an opportunity to make any modifications to their flexible/non-­extreme solution, the next step is for the therapist to help them to develop an action plan whereby they implement their solution in salient situations. The more the client can integrate this plan into their everyday life, the more likely it is that they will implement the plan. This plan is broader than the specific homework

  Unless it is necessary, I tend to stay away from cognitive Cs at this point.

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Ask the client to summarise the session The client and therapist agreeing an action plan is a sign that you are approaching the end of the session. As such, it is a good idea to ask the client to summarise what has been covered in the session. In SST, we suggest that the client does this, rather than the therapist, for two reasons. First, it keeps the client active rather than passive and, second, the client is more likely to be influenced by their view of what was covered in the session rather than by the therapist’s summary of the same. Having said that, the therapist may add a useful point or two that the client omitted from their summary for the client’s consideration. Help the client to specify takeaways and ways to generalise these to other problems

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assignments negotiated in ongoing REBT, and it should be realised by both therapist and client that there may be no opportunity for the client to report back on their progress until a follow-­up session has taken place. The action plan should ideally outline what the client is going to do in broad terms, which flexible/ non-­extreme attitude they are going to rehearse at the same time, which adversities they are going to face in which situations and how often they are going to devote to plan implementation. It is also useful for the client to specify the first steps that they are going to take and identify and deal with any potential obstacles to the execution of the action plan.

The client may well have pointed to what they are going to take away from the session when providing their summary, and if so, I suggest that the therapist underscore this, maybe suggesting that the client may wish to make a written note of the takeaway(s). In SST, it is argued the therapist should not overload the client with takeaways. One or two significant takeaways will suffice. If the client has not mentioned the takeaway(s) in the summary then the therapist should ask them to do so after the client has shared their summary. If possible, it is a very good idea to ask the client to think of other areas of their life to which they could apply the takeaway(s). Bring the session to a close and agree access for further help if requested I am often asked how long a single session should ideally last. This will depend on a number of factors. Some agencies prescribe a session length from 60 minutes to anywhere up to 90 minutes. I currently work providing 30-­minute online video consultations to clients. In my independent practice, I say to clients that sessions last up to 50 minutes. I stress the term ‘up to’ here because the session ends when the session ends and not when the clock says it should end. I personally find that the majority of my single sessions last for less that 50 minutes, but I do wish to stress here that I am discussing my own personal work in SST. REBT therapists who wish to offer SST will need to make their own mind up about this issue. As the therapist brings the session to an end, I suggest covering the following: ▪▪ The therapist should give the person an opportunity after the session has ended to ask anything about the work done in the session that they wished they had asked. However, and vitally, this is not an invitation for them to bring up a new issue. ▪▪ The therapist should give the person an opportunity to tell the therapist anything that has not been mentioned about the issue that they still need to say. Again, this should be done without inviting the client to move on to a different issue.

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▪▪ The therapist should review the issue of the client accessing further help. The options here will be dictated by what services the agency or independent therapist can offer. What is important is that the therapist indicates that each option has equal merit and that the client should choose what is right for them. Here is a sample of such options for the client to select from: –– Opt for another single session. –– Opt for another service offered by the agency/therapist. –– Indicate that today’s session was sufficient. –– Reflect on the session, digest what was learnt, take action and see what happens before making a decision about seeking further help. Some agencies have a policy of contacting the client two or three weeks after the session to check on how things are going for the client and to see if they want further help. In this case, you will see that the option to book further help at the end of the session is not available. At the end of the session, the therapist and client say goodbye to one another and the therapist wishes the client well, hoping that, at least in part, that the client has had their morale restored and can look forward to the future with some degree of optimism. This is the case whether or not the client decides to request further help from the therapist or from the therapy agency.

Pair up with a trainee colleague and take it in turns to be therapist and ‘client’. When taking the role of therapist, please ask your ‘client’ to select a current issue that is pressing for them on which they would like to effect a change. Take up to 50 minutes and see if you can help them to achieve their objective using REBT in SST as described in this chapter. Record the session and review it with the ‘client’. Ask them to tell you what was helpful about what you did and how you could have intervened more effectively with them. Play the session to your REBT trainer or supervisor to get their feedback. After you have adopted the ‘client’ role, review the session with your therapist and give them the same feedback. Tell them what was helpful and suggest ways in which they could have intervened more effectively with you. At the end of this training exercise review what you have learnt from it. In particular, ask yourself what you plan to take away from the exercise that you can implement in your therapeutic work going forward, both in regular REBT and in REBT in a single-­session format.

Get immediate feedback In my view, it is important for the therapist to get a sense that the session had some value for the client and also to see if the help provided was what the client was looking for. Consequently, it is my practice to send the client a form later that day for the client to complete, offering me that feedback. The form that I use asks the client to rate the session on a number of points using a 10-­point scale: ▪▪ How helpful the pre-­session questionnaire that I use was to them. ▪▪ To what extent they felt heard, understood and respected by me.

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▪▪ To what extent the approach that I took was a good fit for them. ▪▪ Overall, to what extent they got what they wanted from the session with me. ▪▪ To what extent they would choose me as their therapist if they wanted another therapy session. I then provide them with an open-­ended opportunity to say if there was anything that was particularly useful to them or anything I could have done to have improved the session for them. Carry out a follow-­up The purpose of a follow-­up session is twofold. First, follow-­up gives the client an opportunity to give feedback on the longer-­term outcome of the session, what was helpful to them and what they would like to have got that they didn’t get. Here a therapist and/or agency can use before and after objective measures if they wish. Second, the client is given an opportunity to evaluate the service they got. This is particularly useful if they were seen in the context of a therapy agency. Here they can give feedback on such issues as how they were received by the agency and how quickly they were seen by a therapist, and they can be asked to give suggestions on how the agency can improve service delivery. Follow-­up usually takes place some months after the single session and is to be distinguished from more immediate requests for feedback and contact from an agency to see if they need more help, usually two/three weeks after the session.

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▪▪ To what extent the client and I discussed what the client wanted to discuss in the session.

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An example of an REBT-­based single session The following session took place within a workshop setting and gives a flavour of how I practise REBT-­ based single-­session therapy (SST). I was giving a one-­day workshop on SST, and what follows was the second of two demonstration sessions I did that day. When I ask for a volunteer, I stress that the person needs to have a genuine current emotional problem with which they would like help and which they don’t mind discussing in front of an audience of their peers. The person in the transcript here has given me their written permission to include it in this book and requested that I use the name Shell Annette when referring to her. The transcript includes my commentary.

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◀   C H A P T E R NINE T EEN  ▶

Windy: OK, Shell Annette, what problem can I help you with today? Shell Annette: It’s anxiety. My anxiety is absolutely through the roof. Windy: Is it? Shell Annette: Yeah.  .  . I feel that I’ve just got no time for me. And I notice when I talk, the urgency all the time in my voice: ‘I need to do this,’ ‘I’ve got to do this.’ I just feel like I’m on a timer all the time to do everything. [I was immediately aware that Shell Annette voiced a number of rigid attitudes which may account for her anxiety.] Windy: OK. And, so, when you volunteered to come up here today, what was that for? Shell Annette: Me. That was for me. Windy: Right. So, you’ve made a start to do something for you. [Right from the start, I am looking for ways of encouraging change. Shell Annette says that she has no time for herself and yet she has done something for herself by volunteering for help. I make this point explicitly.]

Fundamentals of Rational Emotive Behaviour Therapy: A Training Handbook, Third Edition. Windy Dryden. © 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.

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Shell Annette: Yeah. Windy: How did you manage to decide to do that, because you could have not volunteered? Shell Annette: I couldn’t stop my hand going up. I thought, ‘Don’t put it up!’ because I’m not very good at talking in groups. I don’t like being upfront, but I just thought, ‘Do you know, just push yourself through that.’ Windy: Push yourself through the. . .? Shell Annette: Through the fear. Windy: Right. Shell Annette: Because my heart’s absolutely palpitating right now. Windy: Is it? Shell Annette: Yeah. I’m shaking. Windy: Right. So, you’ve made the decision to do something for yourself. Shell Annette: Yes. Windy: Even though it felt like your hand had a life of its own. Shell Annette: Yes. Windy: And, even though you are feeling quite anxious right now, you decided to come up and do it anyway. [I am emphasising the point here that it is possible to choose to do something to help oneself despite being anxious.] Shell Annette: Yes. Windy: OK, all right. So, what do you take from that? Shell Annette: That I’m probably braver than I actually think I am. Windy: And by braver you mean what? Shell Annette: [pause] I think, for a lot of years, I thought I was stupid and thick and I put myself down. And I’ve learned over the last couple of years or few years while I’ve been doing the counselling training that actually I’m not quite that stupid; I can do things. Windy: You can do things and you’re brave. OK. So, tell me a little bit about, if you, again, were to leave here thinking that ‘I’m pleased that I actually volunteered to talk about that,’ what would you have realistically achieved as a result of talking to me today? [In this response, I extrapolate from what Shell Annette has said about her strengths that she is brave and can do things before asking for her goal.] Shell Annette: I think the fact that I’ve put myself out there. . . I think I’d feel quite good in myself, that I’ve actually been brave enough to do that.

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Shell Annette: Yes. [The client makes the point that she has already achieved her goal.] Windy: So, anything else is a bonus? Shell Annette: Yes. Windy: Let’s give you a bonus. I gave him a bonus – let’s give you a bonus. What kinds of things do you make yourself anxious about? [As I have said, this single session took place on a one-­day training course on SST. The interview was the second one that I did on the day and the phrase ‘I gave him a bonus’ refers to what happened in the first session I did that day.] Shell Annette: I’m very busy. I’m a really hard worker. I have a lot to do. And I think I’ve realised I’ve used it over the years as an avoidance. If I keep myself so busy, I don’t have to think about my life, about me, if I just keep myself on the go all the time. Windy: Right. So, when you realised that you were doing that, did that lead to any change? Shell Annette: Yeah. I suppose it calmed me down quite a lot in sometimes being able to relax and think, ‘Shell Annette, just give yourself a little bit of time.’ But I always seem to slip back into it and just have lots of things to do.

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Windy: So, if we stopped the session right now, you would have achieved what you aimed to do?

Windy: What kinds of things are we talking about? Shell Annette: Well, I’ve got my own business, so, every year I’ve got my accounts to do, which is now – stock-­taking. I’m doing a degree at the minute, so I’m busy with that. I’ve got a horse; I’ve got my dogs. Even when I go now and ride my horse, there are some days that I think, ‘Do you know, I’m not going to take my phone today,’ or, ‘I’m going to take my watch off,’ and that’s the time I can truly relax. Windy: You do that, do you? Shell Annette: I do, yeah, at times. I’ve just only recently. . . Windy: So, there are times when you choose to not take your watch with you and to not take your phone with you. Shell Annette: Yeah. Windy: And, at those times, you relax. Shell Annette: Yes. Windy: OK. And you’ve just made that decision? Shell Annette: Just recently, yeah, not too long ago. Windy: Yeah, OK. Is that something that you see that you could do more of? [This is an example of how to capitalise on helpful strategies the client has used in the past to deal with their anxiety.]

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Shell Annette: [pause] Well, yeah, but probably just not at the minute because I’m also in the middle of converting my shop into a flat, so I’m having to arrange everything for that. And, I suppose, what I’m really thinking is just, ‘Thank God I’m finishing this course in May and I’m finished then,’ and then I feel that I’ll have more time, come May. Windy: Right. Shell Annette: But then, knowing me, I’ll fill it with something else. Windy: Right. So, if you weren’t filling all your time up, what would you have to come face to face with? Shell Annette: [pause] I suppose I’d have to come face to face first with me, but then, having said that, I have looked at myself a lot over the last couple of years or few years. Windy: So, you’ve looked at yourself a lot? Shell Annette: Yeah. Windy: And you were saying that you’ve had to come face to face with yourself, and you’ve looked at yourself a lot, and what’s the conclusion? Shell Annette: I think the big thing is. . . through personal therapy it’s building up my self-­worth, which I have been doing because I have very low self-­worth. To build that up, I feel a lot better. I’m actually happy in my own company. I can be on my own. But then I think I go to extremes of probably isolating myself from people as well. Windy: So, you can go to both extremes: you can isolate yourself and you can do the busyness. Shell Annette: Yeah. Windy: So, what would be the ideal balance for you? [I am having some difficulty getting a stable goal from Shell Annette. Here I try again.] Shell Annette: Somewhere in the middle. . . where. . . [pause] Do you know, this question I asked the other day – do you know what I’d love to do? I would just love to sit and watch a film, and I just think, God, that would just be so relaxing, because, as I say, I don’t have time to watch TV. [Shell Annette comes up with a specific activity that embodies her goal.] Windy: Can I just clarify something, in terms of what you mean? Are you saying you don’t have time to watch TV or you don’t make time to watch TV? Shell Annette: [pause] I probably don’t make time to watch TV. Windy: Does that feel differently to say that? Shell Annette: It does, yes. Windy: In what way? Shell Annette: [pause] Because I think, if I always think, ‘Oh, I’ve got this to do, I’ve got that to do, I’ve got the other to do,’ I put myself under pressure, ‘I’ve got to do this, I’ve got to do that, I’ve got

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[Having helped Shell Annette to see that there is a difference between ‘making time’, which involves an active choice, and ‘having time’, which does not and which leads Shell Annette to rehearse a number of rigid ideas, I return to the specific goal.] Windy: Right, OK. And do you have any particular film that you’d like to watch? Shell Annette: Any kids’ film. I love kids’ films. Windy: Any kids’ film. Do you have a TV? Shell Annette: I do, yeah. Windy: Do you have satellite TV? Shell Annette: Yeah. Windy: Sky Disney channel or something? Shell Annette: Well, I’ve just bought a new television and it’s got Netflix on it. So, I could actually go on to that.

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to do the other,’ where it feels great, in fact, if I was to think, ‘Do you know, actually, why don’t you make that hour or two hours to do that?’ That would really relax me.

Windy: OK. When would you like to do that? [Having ascertained that Shell Annette agreed to watch a kids’ film on Netflix, I asked her to specify a time when she would do this.] Shell Annette: When? Windy: Yeah. Shell Annette: [pause] I’d like to do it now, tonight. Windy: OK. What time? Shell Annette: 7 o’clock. Windy: 7 o’clock, OK. So, let’s see if we can introduce a bit of realism here. At 10 to 7 you start thinking, ‘I haven’t got time for this, because I have to do that, I have to do this, I have to do that, I have to do that.’ Let’s suppose that happens, right? How are you going to respond to that part of yourself? [Having agreed a goal with Shell Annette, I ask her to imagine an obstacle to achieving it which she mentioned earlier and how she would address it.] Shell Annette: I’m going to say, ‘Make time. Make that time for you.’ Windy: Yeah. And I might suggest that you say, ‘Actually, no, I don’t have to do that.’ Shell Annette: Yeah. Windy: It’s a choice. [Here I suggest that Shell Annette responds to her have tos and use the concept of ‘choice’ discussed earlier.] 211

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Shell Annette: Yeah. Windy: It’s not a have to. Shell Annette: Yeah. Windy: OK? So, maybe, if you kind of think in terms of, rather than have tos, you think in terms of choices, because, when you get into the zone of choice, if you like, or the land of choice, I think I even had the sense when you were doing that you found that a bit more relaxing, as opposed to ‘I have to do this, I have to do that,’ as opposed to ‘No, I don’t. I can choose.’ Shell Annette: Yeah. Windy: Which one is associated with anxiety and which one is associated with calming down a bit, do you think? Shell Annette: Well, it’s me putting myself under pressure, isn’t it? It’s me thinking, ‘I have to, I have to.’ Windy: Yeah. And if you say, ‘No, I don’t; I can choose to,’ how do you feel? Shell Annette: That makes it so much easier and so much calmer. Windy: So, can you see the relationship between your anxiety and, on the one hand, all these have tos that you’re initially coming up with? Shell Annette: Yeah. [Here, I ask Shell Annette to reflect on the connections between her rigid and flexible basic attitudes (B in the ABC framework) and her unhealthy and healthy negative emotions (C in the ABC framework). I am using this framework here in response to what Shell Annette has said during the course of the session beginning at the outset.] Windy: By the way, it’s a bit like what I was saying to Steve – that will be your default position, but, just like on a computer, just because something defaults to something, it doesn’t mean that you have to go along with it. [Steve was the first client I saw that day.] Shell Annette: Yeah. Windy: You can choose to change it. Shell Annette: Yeah. Windy: So, I just wanted to be realistic: that you may well find yourself with those shoulds, but you say, ‘Uh-­uh, no, wait a minute, no, I don’t have to. I have a choice.’ Shell Annette: Yeah. Windy: OK. So, if you go home at 10 to 7 and part of you says, ‘No, I don’t have time for this because I should be doing that,’ you can say, ‘No, I don’t have to. I have a choice.’ Can you imagine doing that?

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Windy: OK, good. Where would you be? Shell Annette: Sorry? Windy: Where would you be in your house doing that? Which room? Shell Annette: In the living room. Windy: Yeah? So, can you see yourself initially starting to have those shoulds and then being aware of that and saying, ‘No, no. I don’t have to. I have a choice. I can choose to make time for myself right now and sit down and watch’? Shell Annette: Yeah. Windy: Can you imagine yourself doing that? Shell Annette: I can see myself doing that. Windy: And how do you feel when you do that? Shell Annette: I feel a lot better, a lot calmer.

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Shell Annette: Yeah, I can imagine doing that.

[Here I use imagery to encourage Shell Annette to rehearse the solution in the session.] Windy: OK. So, again, I think that when you have started to look at yourself and started doing some of the work that you’ve mentioned, that you’ve started to develop a sense of self-­worth, self-­ esteem. You’ve actually seen the benefits of what happens when you can choose to make time by taking your watch off and you can choose to make time by not taking your phone and you can choose to make time to sit down and watch a film. Now, do you have any fear about what would happen if you did more of this and became more focused on your own development, your own relaxation? Do you have any fears about what would happen in your life if you do that? Shell Annette: What, if I was to take more time for me? Windy: Yeah. Is there a downside for you? Shell Annette: The downside is: would I get everything done that I have to do? That would be the downside. But the upside would be it would be absolutely great for me. Windy: OK. So, the downside is, ‘Would I get everything done that I have to do?’ Shell Annette: Yeah. Windy: OK. Well, let’s just see. Are you breathing at the moment? [At this point my intention is to help Shell Annette to see that she has only a few ‘needs’, things she has to have or she will die, but I neither explain what I am doing nor make the most of this intervention.] Shell Annette: Yes. Windy: OK. That’s good, because you have to do that, don’t you, because otherwise, if you don’t do that, what?

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Shell Annette: I’ll die. Windy: OK, so you’re doing that? Shell Annette: Yes. Windy: OK. Do you drink water? Shell Annette: No, not very often. Windy: Well, you drink. . .? Shell Annette: I drink coffee. Windy: OK, well, that contains water, and you know you have to do that. Do you know why? Shell Annette: To keep me hydrated. Windy: Yeah, because if you don’t do that, what? Shell Annette: I’ll die. Windy: OK. So, that’s two needs you’re doing. So, what other needs do you have to do? Shell Annette: [pause] Look after myself. Windy: OK, right, you can say that, but you didn’t have that in mind when I asked you about the fear. When you said, ‘I may not be able to do everything I have to do,’ you didn’t have looking after yourself in mind, did you? Shell Annette: No. Windy: What did you have in mind? Shell Annette: That I wouldn’t have time to do it. Windy: What? That’s what I’m saying. What wouldn’t you have the time to do, because you’ve got the time to drink water, you’ve got the time to breathe, you’ve got time to look after yourself? Now, what other have tos do you not have time for? Shell Annette: What do you mean? Like work? Windy: I don’t know. Shell Annette: Yeah, work and getting everything organised for downstairs, to get it in on time when people are coming into work, like the plumber, the electrician, getting everything on time for them. Windy: And are they dictating their time to you or are you dictating the time to them? Shell Annette: A bit of both. Windy: OK. What would happen if you took more in charge with these tradesmen, that you were in charge more? Shell Annette: Well, that would help if I was in charge, but I’ve got to go along with them when they can actually fit in to do the job.

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Shell Annette: Well, they wouldn’t be able to come and do the job that day. Windy: And therefore? Shell Annette: It would put it back for another day. Windy: Yeah, and, if it was put back another day, how bad would that be for you? Shell Annette: I was just going to say I’d die, but I wouldn’t really, would I? [While my ‘needs’ intervention fizzles out, Shell Annette does come to see that not having her so-­called ‘needs’ met will not be a life and death matter. As will be seen below, she resonates with this idea.] Windy: Right. Well, I don’t know. We could do the experiment, but do you see what I’m saying? It’s almost like you’re reacting as if terrible things will happen. Shell Annette: I know, yeah. Windy: As opposed to things being inconvenient, you see?

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Windy: OK, all right. But what would happen if you don’t manage to fit in with them?

Shell Annette: Yeah. Windy: So, what do you think would happen if you stopped looking at things as a life and death matter, and started looking at things as either inconvenient or convenient? [Here, I show Shell Annette that she can generalise this solution.] Shell Annette: Yeah. Windy: Right? Shell Annette: Yeah, you’ve really hit it on the head there. Windy: Yeah? Shell Annette: Yeah. Windy: OK. So, why don’t you summarise what you’re going to take away today? [Shell Annette indicates that she resonates with the idea of seeing things as convenient or inconvenient as opposed to as life or death. As we are nearing the end of the session, I use this as an opportunity to ask her to summarise the session.] Shell Annette: I’m going to take away the urgency to have to do things – the language. Giving myself more time and knowing I have the choices to do that. Windy: And to start seeing things as inconveniences rather than life or death matters. Shell Annette: Yeah. Windy: But I would recommend that you keep drinking liquids and keep breathing. Shell Annette: Yeah.

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Windy: I think that’s important. [I end the session on a lighthearted note, which helps to bring about closure.] Shell Annette: Yeah, I’ll do that. Windy: Right. Are we done? Shell Annette: Yeah. Windy: Are you happy? Shell Annette: Yeah. Windy: Good. OK, let’s see what they have to say. Shell Annette: Thank you. [I invite the audience to ask me and the client questions or make observations.]

XX Commentary In this chapter, I have outlined the features of my own approach to single-­session one-­at-­a-­time therapy, which is a blend of general SST therapy concepts and principles from working alliance theory, pluralism and REBT. While it is unlikely that any single session will show an SST therapist’s approach in full, I think that the above session demonstrates the following elements of my approach. Strengths-­based emphasis. From the outset, I was looking to identify and help Shell Annette use her strengths. I highlighted the fact that Shell Annette was acting bravely by volunteering for the interview with me even though she felt anxious. I also took her phrase ‘I can do things’ and emphasised it as a maxim of competence rather than incompetence for the session. These features show strengths-­based SST in action. Previous helpful strategies in addressing the problem. I was vigilant for anything Shell Annette did in the past that would help her with her current problem. These were taking her watch off and leaving her phone behind. These actions helped her calm down and switch off from her have to-­based behavioural regime. Goal-­setting. While Shell Annette was clear at the outset that anxiety was a problem for her, I initially struggled to help her set a goal. Eventually she said that she wanted to achieve a balance between being busy and isolating herself and that this would be embodied by her taking time to watch a film, an activity that was for her in the same way that volunteering for the session was for her. Focusing on the client as active chooser or at the mercy of have tos. This dynamic of active chooser vs slave to her have tos was a major theme in the interview and is a key part of REBT theory. I helped Shell Annette to see that she had a choice in many areas where she thought she didn’t. Thus, on the issue of time she could choose to view ‘time’ as something that she had none of or as something that she could make for herself. She could choose to see workmen not meeting her schedule as a life or death matter or she could see it as an inconvenience. Given that

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Using imagery to rehearse the solution. As shown earlier, it is a feature of SST that the therapist encourages the client to rehearse the solution, and I did this here by encouraging Shell Annette to use imagery to rehearse sitting down and watching TV, which embodied making time for herself and calming down as a result. Anticipating and dealing with obstacles: preparing to deal with the have tos. It is an important part of REBT-­based SST that the therapist helps the client to anticipate and deal with potential obstacles to goal pursuit. In helping Shell Annette to take a step towards meeting her goal by watching a TV film at an agreed time, I also encouraged her to consider the possibility that just before sitting down to watch the TV film she would think that she did not have time for this because she had to do x or y, and if this happened how she could deal with it. Dealing with doubts, reservations and objections (DROs). It is common for a client to have a DRO to their agreed solution or some other part of the SST process. In the session with Shell Annette, she expressed the fear that if she focused more on her development she would not get everything done that she ‘had to’ do. There followed a discussion where I encouraged her to list her needs, but in retrospect this intervention was too open-­ended and I don’t think she fully grasped the point that I was trying to make. My point was that we have fewer needs than we think we have, and for those needs that we do have we have to devote time to meeting them. So, if looking after herself more is a ‘need’ for Shell Annette then she has to devote time to this. However, I could have done this better.

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her goal was to live a life less dominated by anxiety, she was able to see the role that have tos and life-­and-­death evaluations played in her anxiety and that if she saw life as a matter of choices and inconveniences she could achieve her goal.

Asking the client to summarise. In SST, it is important for the client to take away what they consider to be valuable points of learning from the session. It is thus good practice for the therapist to ask the client to summarise the session as the session draws to a close rather than summarising what transpired in the session for the client. I thus encouraged Shell Annette to provide her own summary. In doing so she emphasised removing the urgency of ‘having to’ do things, giving herself more time and knowing that she has the choice of doing so. Will she implement these takeaways? It is in the nature of a demonstration of SST that I will never know, and ­neither will you! You have now reached the end of this training handbook. I hope that you have enjoyed it, and let me close by hoping that the book has encouraged you to pursue further training in REBT (see Appendix III). I invite feedback to me at [email protected].

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Homework skills monitoring form Listen to the recording of your therapy session and circle ‘Yes’, ‘No’ or ‘N/A’ (Not Appropriate) for each item. For every item circled ‘No’, write down in the space provided what you would have done differently given hindsight and what you would have needed to change in order to have circled the item ‘Yes’. 1. Did I use a term for homework assignments that was acceptable to the client? Yes No N/A

Homework skills monitoring form

◀  APPENDIX I  ▶

2. Did I properly negotiate the homework assignment with the client (as opposed to telling them what to do or accepting uncritically their suggestion)? Yes No N/A

3. Was the homework assignment expressed clearly? Yes No N/A

4. Did I ensure that the client understood the homework assignment? Yes No N/A

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5. Was the homework assignment relevant to my client’s therapy goals? Yes No N/A

6. Did I help the client understand the relevance of the homework assignment to their therapy goals? Yes No N/A

7. Did the homework assignment follow logically from the work I did with the client in the session? Yes No N/A

8. Was the type of homework assignment I negotiated with the client relevant to the stage reached by the two of us on their target problem? Yes No N/A

9. Did I employ the ‘challenging, but not overwhelming’ principle in negotiating the homework assignment? Yes No N/A

10. Did I introduce and explain the ‘no-­lose’ concept of homework assignments? Yes No N/A

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Yes No N/A

12. Did I ensure that the client believed that they could do the homework assignment? Yes No N/A

13. Did I allow sufficient time in the session to negotiate the homework assignment properly? Yes No N/A

Homework skills monitoring form

11. Did I ensure that the client had the necessary skills to carry out the homework assignment?

14. Did I elicit a firm commitment from the client that they would carry out the homework assignment? Yes No N/A

15. Did I help the client to specify when, where and how often they would carry out the homework assignment? Yes No N/A

16. Did I encourage my client to make a written note of the homework assignment and its relevant details? Yes No N/A

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17. Did the client and I both retain a copy of this written note? Yes No N/A

18. Did I elicit from the client potential obstacles to homework completion? Yes No N/A

19. Did I help the client to deal in advance with any potential obstacles that they disclosed? Yes No N/A

20. Did I help the client to rehearse the homework assignment in the session? Yes No N/A

21. Did I use the principle of rewards and penalties with the client? Yes No N/A

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Possible reasons for not completing self-­help assignments XX (To be completed by client) The following is a list of reasons that various clients have given for not doing their self-­help assignments during the course of therapy. Because the speed of improvement depends primarily on the amount of self-­help assignments that you are willing to do, it is of great importance to pinpoint any reasons that you may have for not doing this work. It is important to look for these reasons at the time that you feel a reluctance to do your assignment or a desire to put off doing it. Hence, it is best to fill out this questionnaire at that time. If you have any difficulty filling out this form and returning it to the therapist, it might be best to do it together during a therapy session. (Rate each statement by ringing ‘T’ (True) or ‘F’ (False). ‘T’ indicates that you agree with it; ‘F’ means the statement is false or does not apply at this time.)

1. It seems that nothing can help me so there is no point in trying.

T/F

2. It wasn’t clear. I didn’t understand what I had to do.

T/F

3. I thought that the particular method the therapist had suggested would not be helpful. I didn’t really see the value of it.

T/F

4. It seemed too hard.

T/F

5. I am willing to do self-­help assignments, but I keep forgetting.

T/F

6. I didn’t have enough time. I was too busy.

T/F

P o s s i b l e r e a s o n s f o r   n o t c o m p l e t i n g   s e l f - ­h e l p a s s i g n m e n t s

◀ APPENDIX II  ▶

7. If I do something the therapist suggests I do it’s not as good as if I come up with my own ideas.T/F 8. I don’t really believe I can do anything to help myself.

T/F

9. I have the impression that the therapist is trying to boss me around or control me.

T/F

10. I worry about the therapist’s disapproval. I believe that what I do just won’t be good enough for them.

T/F

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11. I felt too bad, sad, nervous, upset (underline the appropriate word(s)) to do it.

T/F

12. It would have upset me to do the homework.

T/F

13. It was too much to do.

T/F

14. It’s too much like going back to school again.

T/F

15. It seemed to be mainly for the therapist’s benefit.

T/F

16. Self-­help assignments have no place in therapy.

T/F

17. Because of the progress I’ve made, these assignments are likely to be of no further benefit to me.

T/F

18. Because these assignments have not been helpful in the past, I couldn’t see the point of doing this one.

T/F

19. I don’t agree with this particular approach to therapy.

T/F

20. OTHER REASONS (please write them in).

Training in REBT

Training in REBT

◀ APPENDIX III  ▶

1. For further details of training courses in REBT in the UK, contact: a) UK Centre for Rational Emotive Behaviour Therapy Tel: 020 853 4171 www.ukcentreforrebt.com Course bookings: [email protected] b) T  he College of Cognitive Behavioural Therapies (CCBT) offers a UK-based REBT accredited training programme Tel: 020 8674 1233 www.cbttherapies.org.uk Course bookings: [email protected] 2. For further details of training courses in REBT worldwide, contact: Training Co-­ordinator Albert Ellis Institute Tel: 001 212 535 0822 www.albertellisinstitute.org

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References

References Bandura, A. (1977). Social learning theory. Prentice-­Hall. Beck, A. T. (1976). Cognitive therapy and the emotional disorders. International Universities Press. Beck, J. S. (2021). Cognitive behavior therapy: Basics and beyond (3rd ed.). The Guilford Press. Bernard, M. E., & Wolfe, J. (Eds.) (2000). Rational emotive behavior therapy: A resource guide for practitioners (2nd ed.). Albert Ellis Institute. Bordin, E. (1979). The generalizability of the concept of the working alliance. Psychotherapy: Theory, Research and Practice, 16, 252–260. Colman, A. (2015). Oxford dictionary of psychology (4th ed.). Oxford University Press. DiGiuseppe, R. (1991a). A rational–emotive model of assessment. In M. E. Bernard (Ed.), Using rational–emotive therapy effectively. Plenum. DiGiuseppe, R. (1991b). Comprehensive cognitive disputing in rational-­emotive therapy. In M. E. Bernard (Ed.), Using rational-­emotive therapy effectively. Plenum. DiGiuseppe, R., Leaf, R., & Linscott, J. (1993). The therapeutic relationship in rational–emotive therapy: Some ­preliminary data. Journal of Rational-­Emotive and Cognitive-­Behavior Therapy, 11, 223–233. DiGiuseppe, R. A., Doyle, K. A., Dryden, W., & Backx, W. (2014). A practitioner’s guide to rational emotive behavior therapy (3rd ed.). Oxford University Press. Dryden, W. (1985). Challenging but not overwhelming: A compromise in negotiating homework assignments. British Journal of Cognitive Psychotherapy, 3(1), 77–80. Dryden, W. (Ed.) (1989). Howard Young – Rational therapist: Seminal papers in rational-­emotive therapy. Gale Centre Publications. Dryden, W. (Ed.) (1990). The essential Albert Ellis. Springer. Dryden, W. (1994). Overcoming guilt. Sheldon. Dryden, W. (1997a). Dilemmas in giving warmth or love to clients: An interview with Albert Ellis. In W. Dryden (Ed.), Therapists’ dilemmas (Revised ed.). Sage. Dryden, W. (1997b). Overcoming shame. Sheldon. Dryden, W. (1999). How to accept yourself. Sheldon. Dryden, W. (2000). Invitation to rational emotive behavioural psychology (2nd ed.). Whurr. Dryden, W. (2002). Overcoming envy. Sheldon. Dryden, W. (2011a). Counselling in a nutshell (2nd ed.). Sage. Dryden, W. (2011b). Understanding psychological health: The REBT perspective. Routledge. Dryden, W. (2012). How to come out of your comfort zone. Sheldon. Dryden, W. (2013a). The ABCs of REBT: Perspectives on conceptualization. Springer. Dryden, W. (2013b). Coping with guilt. Sheldon. Dryden, W. (2014). Ten steps to positive living (2nd ed.). Sheldon. Dryden, W. (2016). Attitudes in rational emotive behaviour therapy: Components, characteristics and adversity-­related consequences. Rationality Publications.

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Dryden, W. (2019). Single-­session ‘one-­at-­a-­time’ (OAAT) therapy: A rational emotive behaviour therapy approach. Routledge. Dryden, W. (2020). Single-­session one at-­a-­time therapy: A personal approach. Australian and New Zealand Journal of Family Therapy, 41, 283–301. http://dx.doi.org/10.1002/anzf.1424 Dryden, W. (2021a). Rational emotive behaviour therapy: Distinctive features (3rd ed.). Routledge. Dryden, W. (2021b). The working alliance in rational emotive behaviour therapy. Routledge. Dryden, W. (2022). Reason to change: A rational emotive behaviour therapy (REBT) workbook (2nd ed.). Routledge. Dryden, W. (2023). Single-­session therapy: 100 key points and techniques (2nd ed.). Routledge. Dryden, W., Ferguson, J., & Clark, A. (1989). Beliefs and inferences  – A test of a rational–emotive hypothesis: 2. On the prospect of seeing a spider. Psychological Reports, 64, 115–123. Dryden, W., & Neenan, M. (2004). Rational emotive behavioural counselling in action (3rd ed.). Sage. Dryden, W., & Neenan, M. (2012). Working with resistance in rational emotive behaviour therapy. Routledge. Dryden, W., & Neenan, M. (2021). Rational emotive behaviour therapy: 100  key points and techniques (3rd ed.). Routledge. Eagly, A. H., & Chaiken, S. (1993). The psychology of attitudes. Harcourt Brace Jovanovich College Publishers. Ellis, A. (1959). Requisite conditions for basic personality change. Journal of Consulting Psychology, 23, 538–540. Ellis, A. (1963). Toward a more precise definition of ‘emotional’ and ‘intellectual’ insight. Psychological Reports, 23, 538–540. Ellis, A. (1983). The philosophic implications and dangers of some popular behavior therapy techniques. In M. Rosenbaum, C. M. Franks, & Y. Jaffe (Eds.), Perspectives in behavior therapy in the eighties. Springer. Ellis, A. (1994). Reason and emotion in psychotherapy (Revised and Expanded ed.). Birch Lane Press. Ellis, A. (2001). Feeling better, getting better, staying better. Impact. Ellis, A. (2002). Overcoming resistance: A rational emotive behavior therapy integrated approach (2nd ed.). Springer. Ellis, A., & Dryden, W. (1997). The practice of rational emotive behavior therapy (2nd ed.). Springer. Ellis, A., & Joffe Ellis, D. (2011). Rational emotive behavior therapy. American Psychological Association. Golden, W. L. (1989). Resistance and change in cognitive-­behaviour therapy. In W. Dryden & P. Trower (Eds.), Cognitive psychotherapy: Stasis and change. Cassell. Hogg, M., & Vaughan, G. (2005). Social psychology (4th ed.). Prentice-­Hall. Hoyt, M. F., Rosenbaum, R., & Talmon, M. (1990). Effective single-­session therapy: Step-­by-­step guidelines. In M.  Talmon (Ed.), Single session therapy: Maximising the effect of the first (and often only) therapeutic encounter (pp. 34–56). Jossey-­Bass. Hoyt, M. F., & Talmon, M. F. (2014). What the literature says: An annotated bibliography. In M. F. Hoyt & M. Talmon (Eds.), Capturing the moment: Single session therapy and walk-­in services (pp. 487–516). Crown House Publishing. Mahrer, A. R. (Ed.) (1967). The goals of psychotherapy. Appleton–Century–Crofts. Maluccio, A. N. (1979). Learning from clients: Interpersonal helping as viewed by clients and social workers. Free Press. Marks, I. (2005). Living with fear: Understanding and coping with anxiety (2nd ed.). McGraw Hill. Neenan, M., & Dryden, W. (1999). Rational emotive behaviour therapy: Advances in theory and practice. Whurr. Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95–103. Seabury, B. A., Seabury, B. H., & Garvin, C. D. (2011). Foundations of interpersonal practice in social work: Promoting competence in generalist practice (3rd ed.). Sage Publications. Talmon, M. (1990). Single session therapy: Maximising the effect of the first (and often only) therapeutic encounter. Jossey-­Bass. Yankura, J., & Dryden, W. (1990). Doing RET: Albert Ellis in action. Springer. Young, H. S. (1974). A rational counseling primer. Albert Ellis Institute.

INDEX

Index Please note that page references to Figures will be followed by the letter ‘f’, to Tables by the letter ‘t’; References to Notes will contain the letter ‘n’ following the Note number. The abbreviation REBT is used for Rational Emotive Behaviour Therapy. ABC framework  x, xi client’s open-mindedness about  35, 37 complexity of  186, 187, 192 defining 2 situational model  1–2 teaching clients, lateness example  47–49 see also ‘A’s (activated events); ‘B’s (basic attitudes); ‘C’s (consequences) of attitudes; situations; teaching clients the ‘ABCs’ of REBT absolute ‘shoulds’  11, 12–13, 25n1, 45 acceptance 187–188 action tendencies  63, 66, 69 vs. overt actions  18 activating events  x–xii negative  111, 184 see also ‘A’s (activating events) active-directive therapeutic style  23–26, 29 adversity  x, 3n2, 7, 26, 62 facing-the-adversity process  147–148 feeling neutral about  105 not facing  150 see also ‘A’s (activated events); situations affective empathy  23, 32 ‘aide memoire’ for therapeutic tasks  35, 84 Albert Ellis Institute  157, 174 anger discussing anger-related issues  69 focus on ‘badness’ of others  126 and guilt  63, 96 healthy and unhealthy, distinguishing  53, 58t, 63, 65, 68–70, 77, 83, 106, 119 illustrative dialogue  68–69 as a primary or secondary problem  96

anxiety about anxiety  99 anxiety-provoking situations  138, 162 approval 31 assessment of attitudes  87–88 awfulising attitudes  138 and concern  16, 53, 54–61t, 64–67 ego 65 emotional consequences of attitude to  16 and flooding principle  162 generalised 99 healthy or unhealthy  43, 46, 64, 99, 145, 199, 200 helpful or unhelpful  65 meta-emotional problems  96, 99 non-ego 126 performance/fear of being laughed at  88, 91, 93, 177 primary problem  96, 99 REBT-based single session  207 and rigid/extreme attitudes  63, 65, 94 see also awfulising attitudes; rigid/extreme attitudes aphorisms 29 ‘A’s (activating events)  x–xii, 2–5 actual  2, 4, 31 assuming temporarily the truth of  4–5 avoiding ‘A’ causes ‘C’ thinking  75–76, 187 changing 31 defining 2 external and internal events  3–4 extremely negative, effect of  7, 183–184 identifying 83–85 inferred  2–3, 4 ‘neglect’ of past events  5 ‘magic question’ technique  84–85

Fundamentals of Rational Emotive Behaviour Therapy: A Training Handbook, Third Edition. Windy Dryden. © 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.

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‘A’s (activating events) (cont’d) past, present and future  2, 4 theme and its embodiment  83–84 time-dimensional nature of  4 very negative actual  184, 185 see also ABC framework; adversity; ‘Bs’ (basic attitudes); ‘Cs’ (consequences of attitudes); situations ‘as-if,’ acting as  159 ‘asserted badness’ component of awfulising/non-awfulising belief  7, 13 asserted demands  11, 12 asserted preferences  6, 11 ‘asserted struggle’  8, 14 ‘asserted unbearability’  14 assessed problem coming to an agreement about  108 vs. defined problem  101–102 eliciting client’s goal for  102–104, 108–110 assessment process ‘B’s (basic attitudes)  87–94 critical ‘A’s  83–85 emotional ‘C’s  75–81 meta-emotional problems  95–100 selecting a nominated problem  71–73 specific example of nominated problem, selecting  72–73 specifying target problem  71–73 theory-driven method  93 therapist directiveness in REBT  25 two-step approach  87–93 assignments see homework assignments attitudes awfulising see awfulising attitudes basic see ‘Bs’ (basic attitudes) bearability see bearability, attitude of behavioural consequences of  18, 186 vs. beliefs  x–xi, 1n1 distinguishing between flexible/non-extreme and rigid/ extreme see flexible/non-extreme attitudes; rigid/ extreme attitudes effect on inferences  19 emotional consequences of  16 examining see examination of attitudes extreme/non-extreme  125–126, 130–131 flexible see flexible/non-extreme attitudes irrational, disputing  123 misconceptions of REBT regarding  191–192 non-awfulising see non-awfulising attitudes rigid and extreme see rigid/extreme attitudes thinking consequences of  18–19 unbearability see unbearability, attitude of see also ‘B’s (basic attitudes)

authoritative egalitarian, therapist seen as  161 awfulising attitudes  89, 90, 127 continuum of  13 giving up and overcoming DROs  137–138 money model  87 negated 7 unhealthy 13–14 see also non-awfulising attitudes badness ‘asserted badness’ component of non-awfulising belief  7, 13 evaluations of  6–7, 42 of others, focus on  126 very negative events  7 Bandura, Albert  164 bearability, attitude of  6, 7–9 doubts, reservations and objections (DROs)  138–139 perception of exposure to more emotional pain  139 see also unbearability, attitude of Beck, Aaron T.  62 behavioural assignments  159 behavioural change, goal of REBT  30 behavioural consequences of attitudes  18, 186 beliefs vs. attitudes see attitudes rational or irrational  x, 1n1 see also ‘B’s (basic attitudes) betrayal 187 bibliotherapy 155–156 ‘Big I – little i’ technique  135 blame  37, 185 blocks to taking action  149–150 Bordin, E.  32, 36, 101, 154 brainwashing of clients, misconception of REBT  189–190 ‘B’s (basic attitudes)  x–xi, 5–16 assessing 87–94 two-step approach  87–93 associated with negative emotions  9 vs, attitude  x–xi defining xi emotional consequences of  16 healthy vs. unhealthy  62, 186 rational or irrational  x, xi–xii on rigid/extreme attitudes  xi–xii terminology  xi, 1n1 see also ABC framework; ‘As’ (activating events); ‘C’s (consequences of attitudes) CBAF (Cost-Benefit Analysis Form) see Cost-Benefit Analysis Form (CBAF)

cognitive functional 77 negative emotions  53 pragmatic arguments  128 rigid/extreme attitudes  26, 63 subsequent thinking patterns  63 emotional 16–17 extended statements  79–81 see also ABC framework; ‘As’ (activating events); ‘Bs’ (basic attitudes)

INDEX

change actual ‘A’s and situations  31 of attitudes, misconceptions of REBT as to  191–192 behavioural 30 client making different types of  31 client taking responsibility for  34 client’s commitment to  113–122 client’s goals for  31 inferential 30 other people  104 philosophic  30, 190 types within a case  31 choice-based examination method  128–131 cognitive assignments  155–158 cognitive consequences, rigid/extreme attitudes  26 cognitive therapy  xii commitment to change, eliciting from client  113–122 client’s perceived advantages of the problem, responding to  119, 120–122f client’s perceived disadvantages of achieving goal, responding to  119 goals for change  26 and reconsidering the CBAF  122 Socratic questions  119 see also Cost-Benefit Analysis Form (CBAF); goals of REBT; goal-setting concern  43, 46, 48 and anxiety  16, 53, 54–61t, 64–67 un-anxious 44 conditional ‘should/must’  12 confrontation, misconception of REBT  191 consequences see ‘C’s (consequences) of attitudes conventional therapy mindset  193 Coping with Guilt (Dryden)  186 ‘core conditions’  23–24 Cost-Benefit Analysis Form (CBAF)  113–122 completed, example of  116–118 completing  114, 115 example (communicating honestly to others)  117–118f example (sulking)  115–116f, 118, 120–122f general principles  113–118 going over with a client  114 reconsidering 122 see also commitment to change, eliciting from client ‘C’s (consequences) of attitudes avoiding ‘A’ causes ‘C’ language  75–76 behavioural  18, 186 client’s ‘C’ is really an A  78–79 client’s ‘C’ is vague  77–78

defined problem agreeing with client on  102, 108 vs. assessed problem  101–102 eliciting client’s goal for  108 examples of  108–109 goal-setting, steps for  101–110 demands asserted  11, 12 ‘negated’ 6 and non-dogmatic preferences, distinguishing between 42–43 rigid/extreme attitudes  12 see also non-dogmatic preferences desensitisation 161–162 depression healthy or unhealthy  109 illustrative dialogue  105–106 rejection of self  51 and sadness  55, 145 self-pitying 108 devaluation attitude  50 giving up  139–140 see also life-devaluation attitude; other-devaluation attitude; self-devaluation attitude dialectical examination of attitudes  xii, 123n1, 127–128 didactic explanations  28–29 DiGiuseppe, Raymond  27, 127, 155, 173 directive therapeutic style see active-directive therapeutic style disappointment healthy and unhealthy negative emotions  64t negative emotion and meta-emotion matrix  17, 18t and shame  16t, 53, 57t, 145 disclosure of doubts, difficulties and blocks to change  38 of an inferred ‘A’  27 self-disclosure 29 disputing beliefs  xii, 123n1 see also examination of attitudes

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disputing process effects xii preparing client for  123 terminology xii Doing RET (Yankura & Dryden)  165 doubts, reservations and objections (DROs)  136–140, 183, 189 adopting a bearability attitude/giving up an unbearability attitude 138–139 adopting a flexible attitude/giving up a demand  136–138 adopting an unconditional acceptance attitude/giving up a devaluation attitude  139–140 client’s tasks during treatment  38 encouraging client to adopt a non-awfulising attitude/give up awfulising attitude  137–138 perception that awfulising attitude protects from threat 138 perception that rigid attitudes benefit motivation/ determine what is important  136–137 single-session therapy (SST) format  217 zigzag techniques, using  142, 143 see also misconceptions of REBT efficacy expectation  164 ego disturbance issues  156 Ellis, Albert  x, 6, 13, 19, 37 on dialectical examination of attitudes  127–128 first session, approach to  195 on homework negotiation  159, 161–162, 165 on humour  24 on intellectual insight  141 on misconceptions of REBT  186, 188 on money model  39 rated low on warmth by clients  24 on rational-emotive imagery (REI)  144, 145 recording of sessions  195 on rigid/extreme attitudes  xi–xii, 13, 125 on suggestibility and gullibility  37 on therapeutic responsibility principle  37–38 on therapist qualities and style  24–25 therapy work  165 three major arguments (attitudes) used by  127–128 on work and practice  26 emotional catharsis  188 emotional insight  26, 127, 141, 155, 159, 173 goal-setting  106, 107 emotional responsibility principle  37, 184–186 emotional statements, clarifying  43–44 emotions client confusing with inferences about ‘A’s  3 client having difficulty identifying  81

232

distinguishing between emotional terms  63–65 disturbed, misconception that very negative events cause 183–184 identifying 81 inferences contributing to, not determining  62 meta-emotions see meta-emotional problems mixed 17 neglect of in REBT, misconception as to  188 primary 99–100 see also healthy negative emotions (HNEs); meta-emotional problems; negative emotions; unhealthy negative emotions (UNEs); specific emotions emotive assignments  159 empathy, ‘core condition’  23–24 empirical arguments, examination of attitudes  26, 128 empirical ‘should’  12 environmental change  31 envy, healthy or unhealthy  16t, 60t, 63, 64t, 145, 146, 156 events see ‘A’s (activating events); situations examination of attitudes  xii, 123–140 ‘Big I – little i’ technique  135 choice-based examination method  128–131 cognitive assignments  155 determining which attitude client would like to have been taught 131 dialectical  xii, 123n1, 127–128 helping client to see relevance  123–124 helping client understand what is involved  124–125 misconceptions of REBT  191 persuasive arguments, use of  131, 132–134t questions, asking  27 rigid/extreme and flexible/non-extreme helping client understand components of  125–126 helping client understand one only  126 number of attitudes to examine  125–126 teaching children example  131 use diagrams  135–136 using the three major arguments  26, 127–128 see also attitudes; ‘B’s (basic attitudes) external events  2, 3–4 extreme/non-extreme attitudes choice-based examination method  130–131 components 125–126 failure, fear of  149–150 fear DROs, dealing with  217 illustrative dialogue  160, 161, 162, 208, 213, 214 lift phobia  162 of rejection  175

taking action without rehearsing  150 unconditional self-acceptance  9–10 zigzag techniques, using  141 see also rigid/extreme attitudes flooding/full exposure principle  162 follow-up, carrying out  205 Freud, Sigmund  194n2

INDEX

spider phobia  31 see also anxiety feedback, immediate  204–205 Feeling Better, Getting Better, Staying Better (Ellis)  156 feelings absence of  77 asking non-causal questions  28, 76 client’s ‘C’ is really an A  78–79 desire to feel neutral about negative events  105 disturbed 184 extended thoughts about  79–81 hypothesis testing  27 vague statements about  77–78 see also emotions flamboyant therapist actions  29 flexible/non-extreme attitudes  xi–xii, 5–10 anxiety 162 attitude change  30 basic attitudes  62 bearability 7–9 conviction, strengthening  141–151 flexible/non-extreme attitudes, suggesting teaching to others 146 helping client identify and overcome blocks to taking action 149–150 helping client plan to face adversity  147 helping client to rehearse in different ways  148 helping client to vary audibility of rehearsal  148 helping client to vary strength of their rehearsal  148 repetition, importance  150–151 suggesting client avoids use of safety-seeking strategies 147 suggesting client rehearse flexible/non-extreme attitudes 147–148 taking action  146–151 zigzag techniques, using  141–144 defining characteristics  5t dialectical examination  xii, 123n1 distinguishing from rigid/extreme  20–21t, 65–66 four types  5t helping client to rehearse in different ways  148 homework assignments  162 identifying 155 inferential change  30 misconceptions of REBT  191 non-awfulising 6–7 number to examine  125–126 and rational beliefs  1n1 remorse 186 SST format, helping client examine in  202 suggesting client rehearse when facing adversity  147–148

genuineness, ‘core-condition’  24 Goals of Psychotherapy, The (Mahrer)  29, 101 goals of REBT  29–31 attitude change  30 behavioural change  30 ideal vs. the actual  29 inferential change  30 philosophic change  30, 190 goal-setting 101–112 asking for a specific example  102 assessed problem, eliciting client’s goal for  102–104, 108–110 best friend’s suggestion  103 for client’s broad problem  110–111 defined problem agreement on  102, 108 assessment of  108 eliciting client’s goal for  102–103 effective, steps for  101–110 imagery 103 nominated problem, specific example  101–110 personal development (PD) goals, promoting  111–112 rigid/extreme attitudes, goals perpetuating  105–106 seeking intellectual insight  106–107 single-session therapy (SST) format  216 target problem, specifying  25 therapist-suggested options  103 time projection  103 unobtainable/unrealistic goals  103–107 changing impersonal negative events  104 changing other people  104 desire to feel neutral about negative events  105 worst enemy’s suggestion  103 Golden, W. L.  168 gradual desensitisation principle  161, 162 guilt  2, 3, 63 and anger  63, 96 goal-setting 110 and remorse  64, 78 gullibility 37

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healthy basic attitude (HB)  186 healthy negative emotions (HNEs) clients’ misconceptions about  77 diagrammatic summary of  53, 54–61t, 62 distinguishing from unhealthy  63–67 feeling upset  44 healthy distress  184 misconceptions of REBT  188 rational-emotive imagery (REI), using  145, 146 rigid vs. flexible attitudes  50 self-depreciation vs. unconditional self-acceptance attitudes 50–51 see also negative emotions; unhealthy negative emotions (UNEs) HNEs see healthy negative emotions (HNEs) homework assignments  153–172 challenging, but not overwhelming principle of negotiation 161–163 clients’ reasons for non-completing  181–182 goals, focusing on  154–155 increasing change of completion client beliefs and skills  164 client understanding nature/purpose  166 client writing down homework details  169–170 eliciting client commitment  167–168 helping client specify when/where and how often  167 homework logically follows therapy  166 ‘no lose’ concept  163–164, 181 rehearsing homework during therapy  170–171 rewards and penalties principle  171 therapist allocating time  165 troubleshooting obstacles  168 monitoring  172, 219–222 negotiating 153–172 challenging, but not overwhelming principle  161–163 purpose of, discussing with client  154–155 reviewing 173–182 best time for  174 capitalising on client’s success  178–179 checking if client has changed nature of homework 174–176 dealing with client not doing homework  181–182 finding out what client learned  177–178 putting reviewing on session agenda  173–174 responding to client’s ‘failure’  179–181 self-help assignments, reasons for not completing 223–224 skills monitoring form  219–222 terminology for  153–154 types of assignment

behavioural and emotive  159 cognitive 155–158 imagery 158 listening 157–158 reading 155–156 unbearability, attitude of  161–162, 168 How to Accept Yourself (Dryden)  156 How to Come Out of Your Comfort Zone (Dryden)  156 Hoyt, Michael  194, 197 humour, ‘core condition’  24 hunches  3, 27 hurt vs. sorrow  105 ideal ‘should’  12 imagery assignments 158 goal-setting 103 rational-emotive imagery (REI)  144–146 single-session therapy (SST) format, example 217 immediate help, requirement for  194 inferences/inferred events accurate representations of reality  30 and actual events  2–3 adversities as  62 contributing to, not determining, emotions  62 distorted 63 effect of attitudes on inferences  19 forming inferences  2 hunches, as  3 hypothesis testing  27 past, present and future  4 and ‘personal domain’  62 inferential change, goal of REBT  30 inferred ‘critical A,’ assuming truth of  4–5 informed consent, importance  196–197 intellectual insight assignments 173 cognitive assignments  155 defining  106, 127 examination of attitudes  136, 141 psychodynamic 107 reading assignments  156 ‘REBT’ 107 seeking 106–107 and therapeutic style  26 see also emotional insight intelligence  126, 192 interactionism 19 internal events  2, 3–4 interpretation vs. inference  3

jealousy, healthy or unhealthy  16t, 59t, 60t, 63, 64t, 145, 146 Kaiser Permanente clinic, California  194 knowledge, hypothetical-deductive approach to  27 lateness example, teaching REBT  47–49 length of therapy  161, 193 see also single-session therapy (SST) format life-acceptance attitudes  6, 15–16 life-devaluation attitude  11t, 13, 15–16 listening assignments  157–158 logical arguments, examination of attitudes  26, 128 ‘magic question’ technique  84–85 Mahrer, Alvin  29, 101 Matweychuk, Walter  1n1 Maultsby, Maxie C.  144 use of REI with clients  145–146 mental health criteria  111–112t meta-emotions ‘ABC’s of, illustrative example  96–97 addressing before primary emotional problem  99–100 assessing meta-emotional problems  95–100 clinically more important than primary emotional problem 99 defining 17 diagrammatic summary of  98f focusing on as target problem  97, 98f, 99–100 healthy or unhealthy  17 interfering with client’s primary emotional problem  99 negative emotion and meta-emotion matrix  17, 18t metaphors 29 misconceptions of REBT acceptance encouraging complacency  187–188 ‘advantages’ of the problem  120f, 121f, 122f brainwashing of clients  189–190 clients being told what to feel/what to do  190 clients prevented from finding own solution to problems 190–191 confrontational, being  191 cop-out criticism  185–186 effective only with highly verbal/intelligent clients  192 emotional responsibility principle  185–186 guilt 186 healthy negative emotions (HNEs)  77 neglect of emotions  188 neglect of therapeutic relationship  188–189 neglecting the past  187

over-simplistic 186–187 ‘straightjacketing’ of clients  191 tasks of therapist, regarding  33 that only focus is in changing attitudes  191–192 theory and practice  183–192 very negative events causing disturbed emotions 183–184 see also doubts, reservations and objections (DROs) mixed emotions  17 money model  39–43 brief 49 common trainee errors  42 correcting client’s errors  41–42 distinguishing non-dogmatic preferences and demands 42–43 lateness example as alternative to  47–48 outline of steps  41 summarising correctly  45–46 ‘musts’  11, 12, 190 see also absolute ‘shoulds’; ‘should’

INDEX

irrational beliefs  x, 1n1 see also rigid/extreme attitudes

‘negated awfulising’ component of non-awfulising belief  7 negative emotions distinguishing between healthy and unhealthy  16–17, 18t action tendencies  18, 63, 66 cognitive consequences  53 five approaches to teaching clients  63–67 lack of emphasis in early REBT  53 misconceptions of REBT  182–183, 188, 190, 191 rape/sexual assault  183–185 subsequent thinking patterns  66–67 symptoms 67 teaching clients ‘ABC’s of REBT  51 using different terms  63–65 identifying as healthy or unhealthy  25 negative emotion and meta-emotion matrix  17, 18t not distinguishing between  43–44 qualitative and quantitative models  64t types of healthy and unhealthy  16t see also healthy negative emotions (HNEs); unhealthy negative emotions (UNEs) ‘No Carbon Required’ (NCR) paper  169 ‘no lose’ concept  163–164, 181 nominated problem assessment process  71–73 goal-setting 101–110 linking with client session goal  201 non-awfulising attitudes flexible/non-extreme 6–7 giving up and overcoming DROs  137–138

235

INDEX

non-dogmatic preferences, and demands, distinguishing between 42–43 note-taking, homework assignments  169 other-devaluation attitude  11t, 13, 15–16 overcoming disturbance (OD) goals, working towards 111–112 peer counselling  ix, 73, 85, 97, 100 personal development (PD) goals, promoting  111–112 ‘personal domain’  62, 78, 158 person-centred therapy  27 philosophic change  30, 190 philosophic empathy  23, 24 phobias  31, 162 Practice of Rational Emotive Behaviour Therapy (Ellis & Dryden) 37–38 practice of REBT  23–38 ‘core conditions’  23–24 ethical 189 misconceptions about  183–192 single-session therapy (SST) format  198–203 therapeutic style  24–29 unethical 1 pragmatic arguments, examination of attitudes  26, 128 predictive ‘should’  12 preferential ‘should’  12 primary emotional problems  99–100 problems ABC assessment of specific example  202 broad, goal-setting  110–111 clients prevented from finding own solution to, ­misconception as to  190–191 generalising to others  203 primary emotional  99–100 REBT as a problem-solving approach  36 secondary emotional  77, 95, 96 see also assessed problem; defined problem; meta-emotional problems; target problem, specifying psychodynamic intellectual insight  107 psychological interactionism  19 questionnaires pre-session  197, 198, 204 self-help assignments, reasons for not completing 223–224 questions ABC framework  27 answering honestly  24 employed by REBT therapists  27 examination of attitudes  27

236

hypothesis testing  27 purpose of asking  27–28 theory-driven 27 see also examination of attitudes; Socratic questions rape/sexual assault  183–185 rational beliefs, terminology changes  xi–xii see also flexible/non-extreme attitudes Rational Counseling Primer, A (Young)  156 rational-emotive imagery (REI)  144–146 example from Ellis’s work  144, 145 example from Maultsby’s work  144, 145–146 reading assignments  155–156 Reason to Change (Dryden)  156 recommendatory ‘should’  12 recordings of therapy sessions listening assignments  157, 159 zigzag techniques, using  143–144 relapse prevention  33 remorse  64, 78, 110, 186 rigid/extreme attitudes  xi–xii, 10–16 adversity triggering  3n2 and anxiety  63, 65, 94 awfulising 13–14 basic attitudes  62 choice-based examination method  128–129 cognitive consequences  26, 63 defining characteristics  10t dialectical examination  xii, 123n1 distinguishing from flexible/non-extreme  20–21t, 65–66 extreme/non-extreme attitude components  125–126 failure to emphasise rigid/extreme components  44–45 helping client understand components of  125–126 homework assignments  176 identifying 155 and irrational beliefs  x misconceptions of REBT  184, 191 number to examine  125–126 and rational beliefs  1n1 seeking goals perpetuating  105–106 simple approach to teaching ABCs  50 SST format, helping client examine in  202 and tasks in REBT  34 types 11t unbearability 14–15 see also flexible/non-extreme attitudes Rogers, Carl  23, 24, 188 role-play  51, 149 illustrative dialogue  39–40 Rosenbaum, Robert  194

helping client examine rigid/extreme and non-extreme attitudes 202 illustrative dialogue  199–201 immediate feedback, getting  204–205 immediate help required  194 informed consent, importance  196–197 inquiring about internal strengths and external resources 201 obstacles, accepting and dealing with  217 open-access service  197n9 planned 194 practice 198–203 principles 195–196 sending pre-session information and questionnaire  198 specifying takeaways  203 SST by default  194n3 SST by design  194n4 suggesting the client rehearse the solution in session 202 unplanned 194 situations anxiety-provoking  138, 162 assessment process  71 attitude change  30 aversive 31 bearability, attitude of  139 blaming 37 changing 31 descriptions of actual events  2 emotional pain, causing  139 existing in time  2 external and internal events  2 healthy and unhealthy emotions  77 historical 187 hypothetical 51 imagery assignments  158 impossibility of change  16 inferential change  30 situational ABC model  1–2 therapy 38 threat, perception of  138 training 42 see also adversity; ‘A’s (activating events) Socratic questions combining with didactic explanations  28 examination of attitudes  124 goal-setting 119 purpose of asking  28 SST see single-session therapy (SST) format Star Trek 188 stories 29

INDEX

sadness, and depression  55, 145 safety-seeking strategies, avoiding use of  147 secondary emotional problems  77, 95, 96 see also meta-emotions self-devaluation attitude  9, 11t, 13, 15–16, 130, 158, 186 comparing with unconditional self-acceptance attitude 50–51 self-disclosure 29 self-efficacy theory  164 self-help assignments  35, 106 reasons for not completing  223–224 books  155–156, 157 cognitive assignments  155 and intellectual insight  106 reading assignments  155–156 skills 35 writing own material  156 see also homework assignments sexual assault  183–184 shame and disappointment  16t, 53, 57t, 145 shame-attacking exercises  159 ‘should’ absolute  11–13, 25n25, 45 advisory 25n1 different ways of using word  12–13 single-session therapy (SST) format  193–205 ABC assessment of specific example of problem  202 access to further help, agreeing  203–205 agreeing first steps, dealing with potential obstacles  203 asking client to summarise  203, 217 asking what help is required  198 brief therapy required  194 checking previous action by client  201 closing session  203 conventional therapy mindset  193 dealing with DROs  217 Ellis’s approach to first session  195 end of session goals, checking  199–201 ensuring person understands nature of  198 example 207–217 focusing on client as active chooser  216–217 goal-setting 216 imagery, using to rehearse the situation  217 previous helpful strategies  216 strengths-based emphasis  216 follow-up, carrying out  205 generalising to other problems  203 helping client develop action plan  202–203

237

INDEX

structure to therapy  25, 191 subsequent thinking patterns  63, 66–67 suggestibility 37 symptoms-based approach  67 Talmon, Moshe  194 target problem assessment process  71–73 meta-emotional problem, focus on  97, 98f, 99–100 obtaining specific example of  25 tasks in REBT  36–38 of client applying emotional responsibility principle  37 applying therapeutic responsibility principle  37–38 disclosing doubts, difficulties and blocks  38 showing openness to REBT framework  37 specifying problems  36 taking notes  34 helping client see relevance of/understand  36 showing clients task-goal connection  36 of therapist  32–36 beginning phase  32–33, 35 ending phase  34–35 middle phase  33–34, 35 teaching clients ‘ABC’s of REBT assessing basic attitudes  87 cognitive assignments  155 distinguishing between flexible/non-extreme and rigid/ extreme attitudes  66 distinguishing between HNEs and UNEs  51 failure to clarify vague emotional statements  43–44 failure to emphasise rigid/extreme components of attitudes 44–45 hypothetical teaching examples  29 lateness example  47–49 money model  39–43 reading assignments  156 recommended steps  47 self-depreciation belief and unconditional self-acceptance belief, comparing  50–51 simpler ways  49–51 tasks of therapist  33 Ten Steps to Positive Living (Dryden)  156 theory of REBT  1–21 activating events see ‘A’s (activating events) basic attitudes see ‘B’s (basic attitudes) consequences of attitudes see ‘C’s (consequences) of attitudes misconceptions about  183–192 situational ABC model  1–2

238

see also situations and testing of hypotheses  27 see also attitudes; flexible/non-extreme attitudes; rigid/ extreme attitudes therapeutic alliance/relationship homework assignments  160 issue of neglect by REBT therapists  188–189 misconceptions as to  188–189 unequal, misconception as to  189 working alliance  161 therapeutic style  24–29 active-directiveness  23–26, 29 structure to therapy  25, 191 therapist activity  26–29 didactic explanations, providing  28–29 hypothesis testing  27 questions, asking  27–28 teaching methods  29 thinking consequences of attitudes  18–19 three major arguments see empirical arguments; logical arguments; pragmatic arguments time projection  103 training courses in REBT  ix, 225 exercise 156 treatment process client’s tasks during applying emotional responsibility principle  37 applying therapeutic responsibility principle  37–38 disclosing doubts, difficulties and blocks  38 showing openness to REBT framework  37 specifying problems  36 ‘drop-outs’ 194 feeling better vs. getting better  33–34 relapse prevention  34 therapist’s tasks during beginning phase  32–33, 35 ending phase  34–35 middle phase  33–34, 35 triggering events see ‘A’s (activating events) unbearability, attitude of  14–15 blocks to taking action  149 doubts, reservations and objections (DROs)  138–139 homework assignments  161–162, 168 see also bearability, attitude of unconditional acceptance  139–140 ‘asserted complexity/unrateability/fallibility’ component 10 ‘core condition’ of  24

rigid vs. flexible attitudes  50 self-depreciation vs. unconditional self-acceptance attitudes 50–51 see also anger; anxiety; emotions; healthy negative emotions (HNEs); negative emotions

INDEX

‘negated global negative evaluation’ component  9–10 ‘negatively evaluated aspect’ component  9, 10 unconditional life-acceptance  9 unconditional other-acceptance  9, 10, 126, 140 unconditional self-acceptance  9, 10, 125, 130, 150, 158 examination of attitudes  139, 140 misconceptions of REBT  186, 188 teaching clients ‘ABC’s of REBT  50, 51 UNEs see unhealthy negative emotions (UNEs) unhealthy basic attitude (UB)  186 unhealthy negative emotions (UNEs) assessment process  83, 87 correcting client’s errors  41 diagrammatic summary of  53, 54–61t, 62 distinguishing from healthy  63–67 feeling upset  44 misconceptions of REBT  188 rational-emotive imagery (REI), using  145, 146

visual aids  29 ‘walk-in’ clinics  194 WRAP (Windy’s Review Assessment Procedure)  93–94, 202 Yankura, Joseph  165 Young, Howard  156 zigzag techniques, using  141–144 helping client complete a written zigzag form  142–143 helping client to use a voice-recorded version  143–144

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