Daniel DAVID (erratum, 2006), Aurora SZENTAGOTAI, & Eva KALLAY
Babes-Bolyai University, Department of Psychology, Cluj-Napoca, Romania.
When testing a potentially influential theory one usually makes sure to employ the best tests in order to receive strait answers. Surprisingly however, some tests are designed to fail from the very beginning, before implementation, as: (1) they do not in fact examine the theory that is supposed to be investigated and/or (2) they investigate the theory using an inappropriate methodology. In rigorous sciences, situations of this kind are limited because the scientific community does not allow such studies published or run. Unfortunately, this is often not the case for psychology. In this article we present how rational-emotive & cognitive-behavioral therapy has been “distorted” by inappropriate “tests” of its hypotheses. Conclusion and implications for future research are discussed.
Key words: REBT, ABCDE cognitive model of distress, rigorous testing of REBT/CBT
Republished by Nova 2006, (Daniel David, editor)
On the special theory of relativity
In his special theory of relativity, Albert Einstein laid down two postulates: (1) the laws of physics are the same in all reference frames; (2) the speed of light through vacuum (close to 300,000,000 m/s) is constant as observed by any observer, moving or stationary (Einstein, 1961). These postulates led Einstein to the conclusion that if you were moving through space at a constant speed and in a constant direction, the rate at which you would travel forward in time would change. Einstein backed up his theory with sound reasoning showing that indeed, the faster you travel through space, the slower you travel through time. The faster you travel through space, the more massive and the shorter you become in the direction of motion. When we say that time slows down for you, your mass increases, and your length changes, we mean that these are the effects an observer would see from her/his (e.g., static) perspective; you would still assess time, your mass, and your length as you always have. However, someone not moving along with you, would see your watch and heart rate run slow, your mass increase (if they pushed you, you would not accelerate as much as they would expect) and your length in the direction of your motion would seem smaller (there is no length contraction perpendicular on the direction of motion).
Taken literally by professionals less acquainted with the special theory of relativity, this could lead them to hypothesize that people who travel often by plane or who drive high-speed cars should live longer (and possibly be thinner!), of course in the context of the observer’s framework. A test of this hypothesis would be easy to undertake and we think that results would be mixed. With an adequate sample, one might find these effects in some experiments and find no effect in other experiments. Thus, a tentative conclusion would be that the special theory of relativity is promising but more work is needed to prove its main hypothesis!
Such an enterprise however, would be an unproductive one, which may unfortunately look serious! The large magnitude effects described by the theory of relativity occur at very high speeds, close to the speed of light through vacuum, which is close to 300,000,000m/s. Of course, this theory can also be applied to a Newtonian universe (large objects-lower speed) but the effect and its impact on life would be so marginal that it would be difficult to measure and/or even if measured, it would bring nothing beyond the predictions of Newtonian physics. For example, Hafele and Keating (1972) measured the phenomena predicted by the theory of relativity (e.g. time dilatation) in a Newtonian universe (using the speed of a plane). The effect is so low (e.g., several nanoseconds) that its impact on the course of life in a Newtonian universe is insignificant. Potential confirmations of this crude hypothesis – the faster you move (but not close to the speed of light) the longer you live – expressed in a larger effect size (e.g., days rather than nanoseconds) could be “false positives” based on type I error or artifacts (e.g., moving around allot might often express an active life style, involving exercising and therefore you may be healthier; this has nothing to do with time dilatation!). To make a long story short, such a test of the special theory of relativity [i.e. moving faster (e.g., by plane, car, train, running) in order to live longer] would be a bad test of a good theory, as the testing context of the theory should be related to speeds close to the speed of light! Someone undertaking such an enterprise in physics would certainly not be taken seriously by the scientific community. However, this is not the case for psychology!
On Rational Emotive Behavioral Therapy
Rational Emotive and Cognitive Behavioral Psychotherapies (REBT/CBT) are based on Ellis’ ABCDE cognitive model of distress (Ellis, 1962; 1994). According to Ellis’ cognitive model, people experience undesirable activating events (A), about which they have rational (i.e., adaptive or functional) and irrational (i.e., maladaptive or dysfunctional) beliefs (cognitions) (B). These beliefs lead to emotional, behavioral, and cognitive consequences (C). Rational beliefs (RBs) lead to functional consequences, while irrational beliefs (IBs) lead to dysfunctional consequences. Patients who engage in REBT/CBT are encouraged to actively dispute (i.e., restructure) (D) their IBs and to assimilate more efficient (E), adaptive, and rational beliefs, with a positive impact on their emotional, cognitive and behavioral responses. Feelings that follow IBs regarding negative events are called dysfunctional negative feelings (e.g., anxiety), and those following IBs about positive events are called dysfunctional positive feelings (e.g., elation after learning that your work was praised by all graders, related to the belief that “Everyone MUST only say positive things about me!”). Feelings that follow RBs regarding negative events are called functional negative feelings (e.g., concern), while those following RBs about positive events are called functional positive feelings (e.g., happiness).
According to one version of the REBT/CBT theory, (Ellis, 1994; Ellis & Harper, 1975), dysfunctional feelings (e.g., anxiety) are qualitatively rather than quantitatively (i.e., intensity) different from functional feelings (e.g., concern) and they are always accompanied by their corresponding functional negative feelings (both anxiety and concern). However, functional negative feelings (e.g., concern) may exist independently of dysfunctional negative feelings (e.g., anxiety). According to a second version of the REBT/CBT theory (Ellis, 1962; Ellis & Harper, 1961) dysfunctional feelings (e.g., anxiety) are quantitatively (i.e. intensity) different from functional feelings (e.g., concern means lower anxiety).
RBs are: (a) pragmatic in that they help people achieve their basic goals; (b) logical (non-absolutistic); (c) reality-based, meaning they are consistent with reality; and/or (d) flexible. Conversely, IBs are: (a) non-pragmatic, in that they prevent people from achieving their basic goals, (b) illogical (absolutistic) (c) non-reality based, that is, inconsistent with reality, and/or (d) rigid.
Ellis initially described eleven irrational beliefs (Ellis, 1962) (e.g., “it is horrible when things are not the way we like them to be”). In time, his theory has evolved (e.g., DiGiuseppe, Leaf, Exner, & Robin, 1988; Ellis, 1994; Wallen, DiGiuseppe, & Dryden, 1992), and it now highlights four categories of irrational cognitive processes: (1) demandingness; (2) awfulizing/catastrophizing; (3) low frustration tolerance; and (4) global evaluation and self-downing. All four categories can be applied to multiple contents (e.g., achievement, affiliation, comfort). Demandingness (DEM) refers to absolutistic requirements expressed in the form of “musts”, “shoulds”, and “oughts” (e.g., “I must pass the exam”). Awfulizing (AWF) refers to an individual’s belief that a situation is more than 100% bad, and worse than it absolutely could be (e.g., “It is awful that I haven’t passed the exam”). Low frustration tolerance (LFT) refers to an individual’s belief that he/she will not be able to endure situations or to have any happiness at all if what he/she demands must not exist, actually exists (e.g., “I cannot stand not passing the exam”). Global evaluation (GE) appears when individuals tend to overgeneralize about others, themselves, and the world. In clinical setting, GE is typically expressed as self-downing (SD); that is, individuals tend to be excessively critical of others, the world, and themselves, and to make global negative evaluations (e.g., “I am stupid and worthless because I haven’t passed the exam”). These IBs may refer to: one’s own performance, other people, and/or life conditions. The counterparts to IBs are RBs: (1) desires rather than demands. Individuals are taught to express their beliefs in the form of wishes, wants, and preferences rather than escalating into dogmatic “musts”, “shoulds”, “oughts”, and so on (e.g., “I really want to pass the exam. Nevertheless, I am aware that it’s not written anywhere that it absolutely must happen”); (2) moderate evaluation of badness rather than awfulizing. In REBT individuals learn to evaluate a negative event as bad rather than awful (e.g., “It is very bad indeed that I have not passed the exam, but this is not the end of the world”); (3) statements of tolerance rather than low frustration tolerance. Individuals are taught that they can tolerate discomfort (e.g., “Failing the exam is not a good feeling but I can stand it”); and (4) acceptance of fallibility rather than global evaluation of human worth and self-downing. Clients are taught that no human being can be evaluated based upon a single global rating, and that life conditions are complex – composed of good, bad, and neutral elements (e.g., “I did not pass the exam. It was stupid of me not to prepare enough, but this does not mean that I am stupid and worthless”).
REBT/CBT assumes that most complex human responses (e.g., emotional, cognitive, behavioral and some physiological) are cognitively penetrable. Cognitive penetrability means two things: (a) that a response (e.g. behavior) is an outcome of cognitive processing (i.e., computation) be it conscious or unconscious, and (b) that changes in cognition (i.e., computation) are possible by various cognitive and behavioral techniques and will induce changes in the expressed response (e.g., behavior). It is important to note that the limits of cognitive penetrability are the limitations of REBT/CBT. In other words, because some basic responses are not cognitively penetrable, (e.g., some basic behaviors are genetically determined), they are not typically considered within the realm of REBT/CBT (David, 2003).
Each psychotherapy system has two important components. First, it is based on a theory (based on various assumptions of which one may derive specific models), which generates basic research and second, it has treatment packages as a derivative of the theory, which often generate applied research (sometimes the distinction between basic and applied research is not obvious). Meta-analytic studies (e.g., Engels, Garnefesky, & Diekstra, 1993; Lyons & Woods, 1991) sustain the conclusion that REBT/CBT is an empirically supported form of cognitive-behavioral therapy. However, the efficacy of the treatment package cannot directly validate the theory that it was derived from. A direct test of the theory is needed instead. Since its creation hundreds of papers have been published focusing on the theory of REBT/CBT (for a review see David, Szentagotai, Kallay, Macavei, in press). However, results are mixed. Thus, although accepted that the construct of irrational beliefs is an important psychological construct, the mechanism by which they impact various outputs (e.g., emotional, behavioral) is still unclear (David, 2003).
A correct and rigorous test of the REBT/CBT theory would involve the following as minimum prerequisites (for more details see David, 2003):
(1) the presence and/or manipulation of a stressful event; if available in the cognitive system, rational and irrational beliefs can have an impact, if and only if, they are activated and made accessible by various stressful events.
(2) a separate measure of rational and irrational beliefs. As shown in Table 1, the relations between rational and irrational beliefs may be very complex (Bernard, 1998; David, 2003). With regards to a specific event (A) people can have high irrational beliefs, low irrational beliefs, or no irrational beliefs; similarly and simultaneously, they can have, high rational beliefs, low rational beliefs or no rational beliefs related to the same event (A) (e.g., David, Schnur, & Belloiu, 2002). These potential interactions should be taken into account when we design research and implement statistical procedures.
(3) A sensitive measure of dependent variables:
a. In the case of the first version of the REBT/CBT theory one should separate measures for functional and dysfunctional negative feelings. Measures should be specifically related to feelings the people are assumed to experience during stressful events.
b. Regarding the second version of the theory, one should use sensitive measures of general distress during stressful situations.
c. Special attention should be paid to the constructs of rational and irrational beliefs and the measures of their impact. Measures of rational and irrational beliefs can be classified into four categories: (1) Non-situational specific/Non-individualized (e.g., how we endorse items describing rational and irrational beliefs across various contexts) (e.g., Attitude and Beliefs Scale, DiGiuseppe et.al., 1988); (2) Non-situational specific/Individualized (e.g., what our individualized rational and irrational beliefs are across various contexts) (e.g., Self Demand Scale; Solomon, Bruce, Gotlib & Wind, 2003); (3) Situational specific/ Non-individualized (e.g., how we endorse items describing rational and irrational beliefs in specific contexts like surgery, cancer etc.); and (4) Situational specific/Individualized (e.g., Automatic Thoughts in Simulated Situations, Davidson, Robins, & Johnson, 1993). Taking these distinctions into account, measures of distress should be selected depending on the A (event) and B (beliefs). If the event is very specific (e.g., an imaginary conflict situation) and the measure of beliefs is non-situational
specific/individualized (e.g., conflict-related beliefs), it makes little sense to use general measures of distress or psychopathology (e.g., Beck Depression Inventory); rather we should use measures for conflict-related distress or for distress during that specific event.
Table 1. The relations among rational and irrational beliefs in a stressful situation (e.g., Passing an important exam)
|High Level of Rational Beliefs||Low Level of Rational Beliefs||No Rational Beliefs|
High Level of Irrational Beliefs
|I must pass the exam (high IB)I very much want to make my mom happy by passing the exam (high RB)||I must pass the exam (high IB)It would be nice if I passed the exam and made my mom happy but this is not so important (low RB)||I must pass the exam (high IB)I don’t care about making my mom happy by passing the exam (lack of RB)|
Low Level of Irrational Beliefs
|It would be nice if I passed the exam but this is not so important (low IB)I very much want to make my mom happy by passing the exam (high RB)||It would be nice if I passed the exam but this is not so important (low IB)It would be nice if I passed the exam and made my mom happy but this is not so important (low RB)||It would be nice if I passed the exam but this is not so important (low IB)I don’t care about making my mom happy by passing the exam (lack of RB)|
No Irrational Beliefs
|I don’t care about passing the exam (lack of IB)I very much want to make my mom happy by passing the exam (high RB)||I don’t care about passing the exam (lack of IB)It would be nice if I passed the exam and made my mom happy but this is not so important (low RB)||I don’t care about passing the exam (lack of IB)It would be nice if I passed the exam and made my mom happy but this is not so important (low RB)|
Unfortunately there are no empirical investigations of REBT/CBT to fit all these constraints and therefore, we can firmly say that although hundreds of studies have been designed and implemented to test the REBT/CBT theory (see David, 2003) there is no study actually testing it! Rather, up to now, most studies investigating the REBT/CBT theory are similar to testing the theory of relativity in a Newtonian domain, by not considering the constraints of the relativistic domain. Moreover, the REBT/CBT theory has been misinterpreted and thus, what has been tested in previous research is not the REBT/CBT theory but some misprojection of it in the mind of the investigators. Let us examine these aspects as follows.
Rational Emotive Behavioral Therapy: The Soft Misinterpretation
Many researchers misinterpret the constructs of rational beliefs as reflecting a low level of irrational beliefs (e.g., Malaouff, Schoutte, & McClleland, 1992). Therefore, unlike the original theory (Ellis, 1962,1994), which predicts that in a stressful situation a high level of rational beliefs will be accompanied by (1) high functional feelings and low dysfunctional feelings (in the first version; Ellis, 1994) or (2) low distress (in the second version; Ellis, 1962), it is instead hypothesized that in stressful situations, a low level of irrational beliefs will be accompanied by (1) high functional feelings and low dysfunctional feelings (in the first version e.g., Cramer & Fong, 1991; Cramer & Kupshik, 1993) or (2) low distress (in the second version; Cramer & Fong, 1991; Cramer & Kupshic, 1993). These investigations have therefore used various statistical analyses based on correlational methods to support this theory.
Beyond the obvious misinterpretation of the REBT/CBT theory, statistical tests of this version of REBT/CBT have not been implemented correctly. As shown in Table 1 the relations between rational and irrational beliefs are complex. Therefore, since a low score of irrational beliefs does not necessarily mean a high score of rational beliefs, the correlational analyses between beliefs and distress is meaningless. A low irrational beliefs group may involve a heterogeneous population (low irrational/high rational; low irrational/low rational; low irrational/no rational) and this might affect correlations between beliefs and various measures of distress. This is similar to testing the theory of relativity at very low speeds!
Rational Emotive Behavior Therapy: The Distortion
Many researchers have tested REBT/CBT by simply correlating irrational beliefs with various indicators of distress (e.g., Chang & Bridewell, 1998). While this kind of research might be interesting in its own, it has nothing to do with REBT/CBT. First of all, it misses the “A” component of REBT/CBT model. As we have said before, in order to have an impact, irrational beliefs have to be not only available in the cognitive system, but also activated/accessible. If there is no “A” to access them, their impact is not predictable. Second, this kind of research is limited by the way rational beliefs are conceptualized (e.g., as a low level of irrational beliefs; see the above discussion) and third, by the way the specificity of distress measures in conceptualized as related to the measures of irrational beliefs (see the above discussion). Therefore, this approach is a gross misinterpretation of REBT/CBT, similar to testing the theory of relativity by expecting a length reduction perpendicular on the direction of motion.
Conclusion and Discussion
Similar to Albert Einstein’s special theory of relativity, which has restructured our mindset regarding the stability of time and space, Albert Ellis’ REBT/CBT has restructured our beliefs regarding human mind and the way it works. Many common sense people would probably still find the idea of time and space relativity absurd, or would not understand it; physics however does not care about this and pursues the study of the theory of relativity based on the empirical evidence. Unfortunately, common sense psychology still has a serious impact in psychology, and it often influences standards by which a scientific theory is evaluated. REBT/CBT is not a “comfortable” theory as it questions some basic assumptions of common sense psychology. For example, the idea that an event is not what makes you depressed but the way you see that event, is still unconceivable to many people. Moreover, irrational beliefs are so strongly engrained in our culture and maybe biology, that any attempt to change them can be perceived as an attack by common sense people, and generate strong affect (Ellis, 1994).
Unfortunately, this is also true for some professionals who find themselves uncomfortable confronting their own irrationality (Popa, 2001) and thus develop an (anti) REBT/CBT position based on (pseudo)arguments such as: (1) it does not fit what most people believe; (2) people may find it intrusive and offensive; and (3) irrational beliefs (i.e., awfulizing, demandingness) are not in fact irrational. Therefore, we should avoid using REBT/CBT and instead focus on other cognitive-behavioral approaches. Unfortunately, this focus on inelegant REBT/CBT (i.e., general cognitive-behavioral techniques, which do not directly approach the irrational philosophical assumptions described in this paper, as elegant REBT/CBT does) promotes feeling better rather than getting and staying better (Ellis, 1994).
A strait and rigorous answer to these arguments could be as follows:
Do we need to mind the fact that a psychological theory does not fit what lay people believe? The theory of relativity is not influenced by what lay people may think based on common sense physics (e.g., regarding the stability of time and space) and by the fact that they may not agree with its assertions. The theory of relativity belongs to scientific physics which employs other criteria of evaluating a theory rather than what most common sense people believe. Basically, this kind of arguments against a theory (e.g., it does not fit what most people believe) is a sophism-ad poppulum. Many people arguing for the roundness of the Earth and its rotation around the sun paid with their lives because their position did not fit what most people believed at that time. In a serious science there is no place for arguments based on ad poppulum. We should not care about what common sense people believe but about what data shows, no matter how insensitive this sentence might sound; otherwise, we do not do science, we just pretend doing it.
Taking into account that REBT/CBT is a clinical theory, we should care about how it is presented to clients and patients. But this has nothing to do with the theory itself. How one translates an uncomfortable scientific theory so that it can penetrate common sense people’s minds, is a matter of therapeutic skills. Let us look at an example. One of the main cognitions that seem to mediate panic attacks, according to cognitive-behavioral therapies is catastrophizing (e.g., “I will die”) (Hawton, Salkovskis, Kirk & Clark, 1989). However, REBT/CBT takes a step forward by saying that the irrational evaluation (e.g., “I must not die and it is awful if I die.”) of this cognition (e.g. “I will die”) is the true mediator of panic attacks. A rational evaluation would be (e.g., “I would prefer not to die and it would be very bad if I died, but I am aware and I can accept the fact that it is not written anywhere that things should happen as I want them to happen”). Most cognitive-behavioral therapists only focus on the nonevaluative cognition (“I will die”) during treatment, prompting Albert Ellis (Popa, 2001) to say that: (1) they just beat around the bush and (2) that they promote feeling better rather getting better and staying better (as irrational vulnerability does not change during such treatments). However, no good REBT/CBT therapist would directly tell the patient that his/her belief (e.g. “I must not die and it is awful if I die”) is irrational; this would be good REBT/CBT theory badly applied in clinical practice! Most of the time the focus will be on the more distal mediator (e.g., “I will not die”), as in most CBT therapies, but an REBT/CBT therapist will also gradually approach the problem of death expressed by such an irrational belief (“I must not die; it is awful to die”) in a philosophical and/or metaphorical context by cognitive restructuring and modeling. For example many REBT/CBT therapists teach REBT/CBT theory and change irrational beliefs through metaphors, stories or using the Bible (Johnson & Ridley, 1992; Johnson, Devries & Ridley, 1994). Thus, our professional colleagues who suggest that REBT/CBT may be offensive to clients should understand that there is a clear distinction between REBT/CBT theory (which may be provocative but is shared with professional colleagues in a professional context) and how it is applied to nonprofessional people (which is sensitive and empathic). If one cannot make this distinction between the scientific standards for a scientific theory and how it is received by common sense people or delivered to clients, one fails to understand what a scientific theory means in psychology.
Clinical professionals often tend to consider themselves standards of rationality. Therefore, when confronted with their own irrational beliefs in the literature, they tend to say that there is something wrong with the theory! For example, one colleague tried to argue that the belief “It is awful that I lost my child” is not irrational! “For the mother”, he said, “this is pretty rational”! Again, this is a mixture of science and our commonsense psychology. First of all, we should decompose the discourse of the patient into the ABC model. Thus, the A (i.e., the loss of a child) is evaluated irrationally (e.g., “it is awful”) and this belief makes the mother feel desperate, miserable and/or depressed. We do not question the fact that to her it is pretty clear that the event is awful and this evaluation makes her feel depressed; however, while we accept feelings as they are, this does not mean that her thought is rational! Not all mothers in similar situations will experience depression or despair. Some might evaluate the A in a more rational manner: “It is very bad and painful that I lost my child. I would have done anything humanly possible to prevent this. I would have even given my life for him/her but I have to accept that things are not always as we wish them to be.” This rational belief might generate functional negative feelings rather than dysfunctional feelings (great sadness rather than depression; annoyance rather than anger etc.); and there is nothing wrong with this! A large segment of the population experiences only medium or very low levels of distress in what is supposed to be a traumatic event, while only a smaller percentage of people experiences dysfunctional emotions (e.g., Bonnano, 2004); and again, there is nothing wrong with this!
Based on an extensive review of REBT/CBT fundamental and applied research (see David et al., in press) we believe that: (a) REBT/CBT theory has been many times misunderstood in research (b) incorrect predictions have been derived from this research, and (c) some of the existing data has not been properly interpreted. Despite critical signals from many REBT/CBT professional, mainstream psychology seems to receive REBT/CBT in a distorted manner (e.g., Ellis & DiGiuseppe, 1993). Mainstream psychology continues exploring REBT/CBT in the “how to live longer by moving faster by planes or high speed cars” framework! REBT/CBT is one of the most investigated theories in the field of psychotherapy (David et al., in press) and this kind of research leading to the misinterpretation of REBT/CBT in mainstream psychology is unacceptable. Future research should try to correct some shortcomings of REBT/CBT research methodology and promote high-quality research. REBT/CBT does no need more research: REBT/CBT needs higher quality and programmatic research!
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