Rational Emotive Behavior Therapy in the Context of Modern Psychological Research

Author info: Author name – Professor, Ph.D., Daniel David; Affiliation – Babes-Bolyai University, Department of Clinical Psychology and Psychotherapy (professor), Cluj-Napoca, Romania/Mount Sinai School of Medicine, Department of Oncological Sciences (adjunct professor), New York, USA; E-mails: daniel.david@ubbcluj.ro; daniel.david@mssm.edu

Acknowledgment:

I thank Wiley-Blackwell for the permission to use the text originally published by me in: In R. L. Cautin & S. O. Lilienfeld (Editors-in-Chief), Encyclopedia of Clinical Psychology. Wiley-Blackwell: Hoboken, NJ., in order to create this slightly longer form of my previous article published in the Encyclopedia of Clinical Psychology: Rational Emotive Behavior Therapy (REBT).

Rational Emotive Behavior Therapy (REBT) is the first form of cognitive-behavioral therapy (CBT), founded by the American psychologist Albert Ellis. REBT is an old approach that has seriously evolved from its creation, based on research in the field. Albert Ellis has emerged, in various professional surveys, as one of the main figures in the history of psychology in general, and in psychotherapy and clinical psychology in particular.

Brief History

In 1957 Albert Ellis published his seminal article “Rational psychotherapy and individual psychology”, in which he set the foundation for what he called Rational Therapy (RT). According to RT, simply said, if we want to change various dysfunctional psychological outcomes (e.g., depressed mood), we have to change their main cognitive determinant, namely irrational beliefs. Although this idea can be found in philosophy and/or other medical/psychological approaches before Albert Ellis, he clearly articulated this view in a coherent, scientifically testable paradigm. Thus, Albert Ellis is generally considered one of the main originators of the “cognitive revolution” in clinical psychology, paralleling the “cognitive revolution” in psychology in general; indeed, his seminal book “Reason and Emotion in Psychotherapy” (Ellis, 1962) legitimized the cognitive paradigm shift in the clinical field.

Although RT targeted mainly emotional (not only behavioral) consequences, and used a large variety of “emotive/metaphorical techniques”, it was misperceived by many as ignoring feelings; therefore, in order to correct this misperception, in 1961 Albert Ellis changed the name of RT into Rational Emotive Therapy (RET). However, although RET used a wide spectrum of behavioral techniques, it was itself misrepresented by many professionals as being “too cognitive” and ignoring the behavioral tradition (and thus, its efficacious behavioral interventions). In order to correct this misrepresentation, in 1993 Albert Ellis changed the name of RET into Rational Emotive Behavior Therapy (REBT). In a personal communication in 2005, Albert Ellis said that he would prefer the name “Cognitive Affective Behavior Therapy”, in order to avoid the philosophical issues around the term “rational”; indeed, many professionals did not check the REBT definition of “rational”, but understood it as in various philosophical traditions. This was often detrimental to the scientific status of REBT because instead of resources being focused on the development of the scientific level of REBT, it was often “wounded” in the many philosophical debates (an important component of a scientific paradigm, but not a key one for mainstream science and research). However, Albert Ellis never went on to change the name of REBT again, as he sadly passed way in 2007. After 2007, the Albert Elis Institute, the world center of REBT, started publically and professionally to promote REBT as Rational-Emotive & Cognitive-Behavior Therapy (REBT/CBT), partially to address Albert Ellis’s intention and to better connect REBT to the current CBT tradition that REBT initiated.

REBT (i.e., RT/RET) has been also applied to domains other than mental health. Thus, REBT application to the educational field has generated rational emotive education, to the work environment has generated rational effectiveness training (or REBT coaching), and to pastoral field has generated rational pastoral counseling. A new emerging and developing field is that of using REBT in genetic counseling.

Theory

The general theory of REBT is based on the ABC model (see Walen et al., 1992). Being a scientific approach, the original ABC model of REBT has evolved (and is still evolving) from its initial form. Thus, some original ideas of the theory were confirmed, others were invalidated, and other ideas were added based on research. Therefore, what follows reflects the current state of the art in REBT theory; however, a careful reading also reveals its historical evolution.

According to current REBT theory, the impact of various activating life events (e.g., the death of a close relative; a practical problem; A) on various psychological consequences (e.g., feelings, behavioral, cognitive, psychophysiological reactions; C) is mediated by information processing (cognitions/beliefs; B). Once generated, a C can become a new A, being further processed (reappraisal), thus generating secondary or meta-consequences. An A can therefore be a physical life event (e.g., death of a close relative) and/or a private one (e.g., a depressed mood). Arguably, the ABC model is the general paradigm of all cognitive-behavioral therapies. However, various CBTs differ in the type of information processing on which they focus.

REBT focuses on a specific type of cognition, namely rational and irrational beliefs. Rational beliefs are logically, empirically, and/or pragmatically supported, and generate functional consequences (e.g., functional feelings, adaptive behaviors, healthy psychophysiological reactions). Irrational beliefs are illogical, non-empirical, and/or non-pragmatic, and generate dysfunctional consequences (e.g., dysfunctional feelings, maladaptive behaviors, and unhealthy psychophysiological reactions).

As concerning functional and dysfunctional feelings (i.e., the emotional problem), REBT theory assumes two competing models (see for details David, 2003; David et al., 2005). The first model is a classic one, assuming that dysfunctional negative feelings (e.g., depressed mood, anxiety, guilt, anger) differ from corresponding functional negative feelings (e.g., sadness, concern, remorse, annoyance) mainly in intensity. The second model is an original one, assuming that differences between functional and dysfunctional feelings, be them positive or negative (e.g., sadness versus depressed mood; concern versus anxiety; annoyance versus anger; remorse versus guilt), are mainly qualitative (without eliminating the quantitative components). Data are accumulating now for both models and thus, the problem is still unanswered.

At its core, REBT theory is mainly a motivational one (see David, 2003) that can be seen part of the appraisal paradigm (see Lazarus, 1991; Smith et al., 1993) in the standard emotional theories of general psychology. Therefore, REBT is focused on a particular type of cognitions, appraisal/evaluative or “hot” cognitions (i.e., rational and irrational beliefs), that are strongly involved in the generation of our feelings. In a broad sense, REBT admits that “B” can also include descriptions (e.g., “It is a crowded auditorium”) and inferences (e.g., “I will fail to speak in front of this auditorium”) (e.g., “cold” cognitions; see David, 2003). These can be represented in our cognitive system by production rules (i.e., “if A then do C”) and thus, generate mainly behaviors at “C”. The relations between “cold” and “hot” cognitions” seem to be bidirectional. Indeed, rational and irrational beliefs seem to influence the functionality of descriptions/inferences (see David et al., 2010). However, REBT argues that if cold cognitions are not further appraised by rational and/or irrational beliefs in terms of motivational relevance, they do not generate feelings (see David et al., 2010).

Therefore, when we face various activating events, we come with our own desires (motivational relevance). If we had no desires, we would not experience feelings. Our desires (i.e., primary appraisal) can be formulated irrationally or rationally.

An irrational formulation of our desires involves three components: demandingness (rigid/absolutistic thinking), motivational relevance, and non-acceptance (e.g., “I must succeed, I do my best to succeed, and I cannot conceive not succeeding”). If activating events fit our irrationally formulated desires (motivational congruence), we will experience dysfunctional positive feelings: they are dysfunctional because they reinforce their underlying irrational beliefs. If activating events do not fit our irrationally formulated desires (motivational incongruence), a second wave of information processing follows (i.e., irrational secondary appraisal): (1) frustration intolerance; (2) awfulizing/catastrophizing; and/or (3) global evaluation. Frustration intolerance (e.g., “I cannot stand it”) means that your rigid desires not being met cannot be tolerated (meaning that either you and/or the situation should disappear). Awfulizing/catastrophizing (e.g., “It is awful”) means that your rigidly formulated desires not being met is the worst thing that could happen (or more than 100% bad). Global evaluation means that if your rigid desires are not met, you, others, and/or life are totally bad (e.g., “I am bad, you are bad, and/or life is bad”).
The rational formulation of our desires involves three components: flexible preference, motivational relevance, and acceptance (e.g. “I would prefer to succeed and I will do my best to succeed, but I can accept that sometimes things do not happen the way I want them to happen”). If activating events fit rationally formulated desires (motivational congruence), we experience functional positive feelings. If activating events do not fit rationally formulated desires, (motivational incongruence), a second wave of informational processing follows (rational secondary appraisal): (1) frustration tolerance; (2) badness; and/or (3) unconditional acceptance, generating functional negative consequences. Frustration tolerance means that one assumes the tolerance of not having one’s flexible preferences met, even if it is unpleasant; moreover, positive aspects can be found in other life events. Non-awfulizing (non-catastrophizing) refers to a nuanced negative evaluation (e.g., in terms of badness) of not having your flexible preferences met; recognizing the badness of the situation may even allow us to look for positive experiences elsewhere. Unconditional acceptance is the antidote to global evaluation (self-esteem). More precisely, we do not globally evaluate ourselves (positively or negatively), but we accept ourselves unconditionally and evaluate only specific and discrete aspects of the self (e.g., what we are doing, thinking, feeling); the same idea applies to the evaluation of others and of life.

Rational and irrational appraisals processes can involve various contents. They can refer to your own person (e.g., “I must succeed”), others (e.g., “You must succeed”), and /or life (e.g., “Life must be fair”). Moreover, they can be general (e.g., “People must appreciate me”) and/or domain (e.g., affiliation, academic, comfort) or situation-bounded (e.g., “My wife must appreciate me“). The rational and/or irrational profile can be homogeneous (e.g., a general level of rationality and/or irrationality) and/or heterogeneous, depending on the content (e.g., rational in some domains, irrational in others). The specific combinations of various rational and irrational processes and their content (i.e., rational and irrational beliefs) generate a core theme relating to specific consequences. For example, “depressed mood” seems to involve a core theme of “loss” and specific irrational appraisal components relating to demandingness (irrational primary appraisal) and self-downing (irrational secondary appraisal). Its functional counterpart involves the same theme of “loss”, but preference (rational primary appraisal) and unconditional self/acceptance (rational secondary appraisal) as specific appraisal components. This line of research is still under scientific scrutiny, but several models have already been proposed and tested (see David, 2003).
REBT theory in the form of the ABC model is based on the classic stress-diathesis model. Therefore, irrational beliefs are seen as cognitive vulnerability factors while rational beliefs are considered sanogenic mechanisms. Thus, irrational beliefs are not necessarily associated with dysfunctional consequences; they become associated with dysfunctional consequences only if they are primed by various activating events.

Rational and irrational beliefs develop during ontogenesis, and both genetic and environmental (e.g., parenting) factors have important contributions. Albert Ellis argued that the genetic contribution is very strong, even evolutionarily determined, but this idea is still a subject of scientific scrutiny in genetic and neuroscience-based research paradigms (see David et al., 2010).

General core rational and irrational beliefs are coded in our cognitive system as schemas and/or propositional networks (see David, 2003). In specific situations they bias the perception of the activating events and thus generate specific rational and irrational beliefs, often in the form of automatic thoughts. They are called automatic thoughts because they come to our mind automatically and are specifically related to various activating events. The automatic thoughts once generated, then reinforce and maintain the core beliefs. The same model seems to work for descriptions and inferences too (see Beck, 1995).
In an expanded version of the ABC model (David, 2003), it was proposed that some of the information processing between “A” and “C” could be implicit (i.e., unconscious information processing/cognitive unconscious), either structurally – it cannot be conscious and functions unconsciously (e.g., classical conditioning, implicit expectancies) – and/or functionally – it can be conscious, but often functions unconsciously (e.g., automatization of conscious beliefs). In this framework, classic rational and/irrational beliefs do not immediately mediate the impact of “A” on “C”, but can amplify a “C”, once generated by unconscious information processing, through further appraisal.

The current REBT theory in the form of the expanded ABC model is represented in Figure 1.

Figure 1. The expanded ABC model in the general REBT theory. In the restricted form of the ABC model, it includes only the specific and general rational and irrational beliefs from the “B” component.

There are hundreds of studies testing the REBT theory in the form of the ABC model (for a review see David et al., 2010). Most of them confirmed the main aspects of the theory (e.g., offered support for the “primacy” of demandingness among irrational beliefs), some invalidated various hypotheses (e.g., it has been found that the impact of irrational beliefs on exam distress is partially mediated by response expectancies), while others are still under scientific scrutiny (e.g., the “qualitative” versus “quantitative” distinction between functional and dysfunctional feelings). A main limitation of the various studies testing the REBT theory was that many researchers misunderstood the basic REBT theory. For example, some researchers conceptualized rational beliefs as low levels of irrational beliefs, which is a misunderstanding of the theory. According to REBT theory, functional consequences are generated not by low levels of irrational beliefs, but by high levels of rational beliefs. Low levels of irrational beliefs could also mean a lack of rational beliefs (no motivational relevance). Therefore, current research is focused on elaborating better measures of rational and irrational beliefs (both explicit and implicit measures).

Practice

The practice of REBT (i.e., individual, small and/or large groups, family/couple) is based on the REBT theory in the form of the ABC model (see Walen et al., 1992). It refers to (1) human optimization, (2) health promotion and prevention of clinical problems, and (3) the treatment of mental disorders and other clinical conditions. REBT practice is immersed in the general psychotherapy and clinical field, which provides the “common factors” of REBT practice (e.g., clinical assessment, clinical conceptualization, therapeutic relationship) (see Wampold, 2001).

Based on the ABC model, the REBT intervention uses three classes of techniques. To deal with problems at A, REBT uses a large spectrum of “practical problem solving techniques” such as assertiveness training, social skills training, decision making, conflict resolution, specific problem solving techniques etc. To deal directly with clinical problems at C, REBT uses a large spectrum of “symptomatic techniques”, such as relaxation, hypnosis, meditation (e.g., REBT-based mindfulness), and other coping strategies that aim to change the C without explicitly targeting underling cognitions (B). To etio-pathogenetically change dysfunctional consequences into functional consequences, REBT uses “cognitive restructuring” (e.g., disputation, reframing) techniques aiming to turn irrational beliefs into rational beliefs (first specific and then general beliefs). REBT uses a large variety of cognitive restructuring techniques: (1) logical, (2) empirical; (3) pragmatic; (4) emotive/metaphorical (e.g., metaphors, stories, poems, humor, songs, meditation/mindfulness-based REBT etc.); (5) spiritual; (6) behavioral (fundamental to change not only conscious beliefs, but also implicit processes/unconscious information processing). Moreover, beyond these core REBT cognitive restructuring techniques, REBT agrees with the use of any safe technique borrowed from other psychotherapy schools. These techniques, however, are separated from their original theories, being used in a new “cognitive framework”. REBT thus proves eclectic at the practical level (not at the theory level), a real platform for a possible psychotherapy integration.

Classic (i.e., elegant, preferential) REBT argues that in clinical practice we should start by solving emotional problems (e.g., anger) and then move on to the practical problems (e.g., communication with your wife). Once we change dysfunctional consequences (e.g., anger) into functional consequences (e.g., annoyance) by changing the underlying irrational beliefs (e.g., “My wife must do what I want, otherwise she is bad and I cannot stand it”) into rational beliefs, we are more productive when focusing on the practical problems (e.g., learning communication skills). This is what Albert Ellis called “getting and staying better”, a profound philosophical change.

General (i.e., inelegant) REBT, which Albert Ellis said that fits the general CBT practice, allows various strategies to reduce dysfunctional consequences. For example, we can start with the practical problem (e.g., learning communication skills), and thus reduce the dysfunctional consequences (e.g., anger); however, Albert Ellis would argue that, in this case, our clients will still have the cognitive vulnerability (e.g., irrational beliefs). Or we could start first by restructuring descriptions/inferences (e.g., “I will fail to speak in front of this crowded auditorium”), if they are dysfunctional, and then move to changing irrational beliefs (e.g., “It is awful to fail”); in this case the clients may not be motivated to work on a profound philosophical change, once they changed their dysfunctional description/inferences and feel already better. These strategies are what Albert Ellis called “feeling better”. If getting and staying better also involve feeling better, feeling better does not necessarily involve getting and staying better (e.g., feeling better may involve symptomatic, not etiopathogenetic changes).

Typically, the REBT intervention is focused on the “present problems”, conceptualized by the ABC model. However, if necessary in the therapeutic process, REBT can engage a “historical understanding” of the present problems (e.g., how irrational beliefs were developed in the clients’ life history) and/or even a “here and now” approach (e.g., how irrational beliefs are expressed during the therapy process, in relation to the therapist). This is similar, as a technique, to the “dynamic” of dynamic therapies. The dynamic element of REBT, of moving from one component to another, can facilitate the therapeutic process in some clinical cases (see Figure 2).

Figure 2. A “dynamic” process of ABCs in REBT.

From its creation, REBT has been an “evidence-oriented therapy”. Therefore, several efficacy (how REBT works in controlled conditions – to understand internal validity) and effectiveness studies (how REBT works in real clinical practice – to understand external validity) have been conducted to test REBT. However, initial REBT studies were criticized (1) for using mainly transdiagnostic categories rather than DSM categories and (2) for using an effectiveness approach (e.g., populations and practices as they appear in real clinical practice) rather than an efficacy approach (e.g., randomization, homogeneous symptomatology, rigorous manualization).

Subsequently, REBT studies started to use DSM categories and rigorous controlled designs in testing outcomes (at post-test and follow-up) (e.g., David et al., 2008; Emmelkamp et al., 1991), mechanisms of change (e.g., Szentagotai et al., 2008), and cost-effectiveness (Sava et al., 2009) for various mental disorders (e.g., major depressive disorder). Moreover, REBT was tested in rigorous clinical trials for medical-related disorders (e.g., cancer-related symptoms – Montgomery et al., 2009).

Several large-scale meta-analyses that specifically summarized REBT clinical trials showed that REBT works for a large spectrum of disorders both in adults (Engels et al., 1993; Lyons & Woods, 1991) and children (e.g., Gonzales et al., 2004). Additionally, numerous clinical trials published under the generic label of CBT, supporting its efficacy/effectiveness, use exclusively and/or as an important component, REBT strategies, as described in REBT manuals (e.g., see Montgomery et al., 2009). Also many meta-analyses published under the general heading of CBT, supporting the efficacy/effectiveness of CBT, also include REBT studies. Despite this optimistic image of the impact of REBT in clinical practice, less is known yet, in terms of empirical evidence, about the use of REBT for human optimization and health promotion, as compared to the use of REBT in the clinical field.
Ironically, REBT has been criticized several years ago for using transdiagnostic rather than DSM categories and effectiveness rather than efficacy studies. Today, transdiagnostic categories and effectiveness studies are “hot topics” in the clinical field; thus, a large part of the old REBT research should be re-evaluated because, although its internal validity is not strong, it has a strong external validity.

Specific contribution of REBT to the psychological field (see for details David et al., 2010)

At a general level, the ABC model – as a general framework – is arguably the foundation of CBTs, although various CBT schools can have specific and even divergent definitions of the “A”, (mainly) “B”, and “C”. Also, the construct of rational and irrational beliefs has largely penetrated the classic textbooks in psychology. Additionally, REBT constructs influenced various frameworks of fundamental research in mainstream general psychology, such as the emotion regulation paradigm (Cristea et al., in press), bifactorial (David et al., 2004) and appraisal theories of emotion (e.g., David, 2003) etc.
At a more specific level, the main contributions of REBT are related to:

The role of unconditional acceptance (e.g., of self, others, and life) as a sanogenic mechanisms (along with the role of other rational beliefs). This stimulated positive psychology type of research (e.g. human optimization and happiness; health promotion and rational living). For example, unconditional-self acceptance is the REBT’s original antidote to the well-known construct of self-esteem, which is seen in REBT as a global evaluation mechanism (positive and/or negative), and thus, a cognitive vulnerability factor; The acceptance components of REBT rational beliefs (e.g., of core flexible preferences and unconditional acceptance). REBT’s acceptance construct was a precursor of some of the “third wave CBTs”’s acceptance construct (see Velten, 2007) that was then further developed by this movement on its own; The distinctions between primary and secondary consequences (e.g., feelings). This distinction preceded the current “hot” discussions on meta-emotions;

The REBT’s original qualitative distinction between functional and dysfunctional feelings (be them negative and/or positive). REBT proposed two models concerning the distinction between functional and dysfunctional feelings (“quantitative” versus “qualitative”) and both models are under scientific scrutiny; The distinction between “feeling better”, “getting better”, and “staying better”. This distinction compels us to design complex studies when testing a new therapeutic packages (e.g., to include mechanisms of change, follow-up analyses, and active placebo control conditions).

Limitations

First of all, REBT has all the limitations of a scientific approach to mental health (see for details David et al., 2010). Thus, up to this moment, REBT has not clarified the mechanisms involved in various mental disorders. Future research is need here. Even when the mechanisms are known, REBT does not have the techniques to changes these mechanisms in all patients. Further research is needed here for new innovative techniques (e.g., to control mental contamination) and for better technology assimilation in the classical REBT (e.g., robotics and virtual reality techniques; internet/computer-based REBT).

Second, REBT has been affected by severe misrepresentations in the scientific literature and thus, a large part of its scientific potential is still underused. Let us briefly present some of the main misconceptions:

REBT has sometimes been pictured as very active and directive (even harsh). This is false! Depending on the client and his/her problems, in the context of a sound therapeutic relationship, REBT can be very active and directive and/or very metaphorical;
REBT is “too cognitive”, its main aim being the change of irrational beliefs by cognitive techniques. This is false! The change of irrational beliefs is not an aim in itself; it is a way to turn dysfunctional consequences (e.g., dysfunctional feelings) into functional consequences (e.g., functional feelings), using a large spectrum of cognitive (e.g., logical, empirical) and non-cognitive techniques (e.g., behavioral, metaphorical); REBT has often been confused with Albert Ellis’ style who, occasionally, used acid jokes and strong words. While humor and irony (including self-irony) are important cognitive restructuring techniques, they are implemented depending on the client and his/her problem and based on a sound empathic therapeutic relationship; REBT theory and techniques have often been wrongly portrayed as simplistic, by arguing that a few rational and irrational beliefs cannot explain the large variation of mental disorders; instead, we need specific cognitive models for each disorder (see Beck, 1995). This argument is false! General and classic REBT recognize the specific cognitions model of various disorders, but classic REBT argues that, unless these (more surface) specific cognitions – often descriptions/inferences – are appraised by rational and/or irrational beliefs, they do not have an impact on mental disorders. Moreover, REBT research is seeking for new rational and irrational beliefs involved in various disorders. Therefore, the REBT reduction of pathogenic and/or sanogenic mechanisms to a few core cognitive processes is similar to the reduction operated in neurosciences, where hundreds of mental disorders are related to just a few classes of neurotransmitters and their relations.

References:

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David, Daniel, Guy H. Montgomery, Bianca Macavei, and Dana H. Bovbjerg. 2005. “An Empirical Investigation of Albert Ellis’s Binary Model of Distress.” Journal of Clinical Psychology 61 (4): 499-516.

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Szentagotai, Aurora, Daniel David, Viorel Lupu, and Doina Cosman. 2008. “Rational Emotive Behavior Therapy versus Cognitive Therapy versus Pharmacotherapy in the Treatment of Major Depressive Disorder: Mechanisms of Change Analysis.” Psychotherapy: Theory, Research, Practice, Training 45 (4): 523-538.

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