| Suicide
is a leading cause of death among adolescents.
Admittedly, many would prefer not to talk about
such a morbid topic, yet the realities are clear
if one chooses to look at the statistics produced
by the Center for Disease and Control (CDC). Suicide
rates will continue to climb until more preventative
programs are developed. Cognitive-Behavioral Therapies
(CBT) are designed not only to reactively work
with a suicidal adolescent, but more importantly,
are structured to formulate work in a proactive
manner. Nevertheless, a review of the literature
is disappointing. Moreover, there was a paucity
of research on the application of Rational Emotive
Behavior Therapy (REBT) and its application to
suicidal adolescents.
Rational Emotive Behavior Therapy (REBT) was developed
and is still practiced by Albert Ellis. It is
considered to be one the many cognitive-behavioral
treatment modalities currently used in the mental
health arena. The primary ingredients and major
suppositions of REBT are similar to Beck's and
Young's ideas and all of the other major cognitive
behavioral thinkers' models; however, there are
distinct differences within the REBT model, which
deserve further exploration.
While this paper is not intended to discuss the
properties of REBT extensively, it seems necessary
to first describe some of the major tenets posited
by Ellis. First, according to Ellis and MacLaren
(1998), "rational emotive behavior therapy
is based on the assumption that cognition, emotion,
and behavior are not disparate human functions
but are, instead, intrinsically, integrated and
holistic (p. 3)." Admittedly, this basic
tenet seems in keeping with many of the other
cognitive-behavioral approaches. However, what
separates REBT from the other cognitive behavioral
therapies is not the goal of attempting to change
and/or modify a patient's cognitions, rather it
revolves around REBT's philosophical foundation.
(Ellis, 1983). According to Ellis and Bernard
(1983), the difference between CBT and REBT "is
that CBT does not attempt to modify the overall
philosophy and assumptive world of clients through
the use of disputational methods (p. 9)."
Many of the CBT models seem to be more problem
driven, while REBT appears to take the position
that behavior and/or emotions are simply consequences
of the patient's core belief structure, which
then leads to psychopathology (Ellis & Bernard,
1983). After a comprehensive review of the literature
regarding REBT, I found a paucity of research
pertaining to REBT and its application to suicide.
In fact, a paucity may be generous.
Application of REBT to the Suicidal Adolescent
According to the REBT model most commonly practiced,
there are five key components a clinician must
be familiar with (Dryden, 1995). In an effort
to be brief, the elements will be applied to a
suicidal adolescent, while at the same time attempting
to define each element. The acronym used by REBT
therapists is the "ABCDE's" of REBT.
"A" refers to the activating event.
For example, an adolescent who is contemplating
suicide or is simply thinking about suicide, the
activating event could be as innocuous as a break
up with a girl or boy friend, a poor grade on
a test or simply an argument with a friend. "B"
stands for the adolescent's rational or irrational
belief about A. For example, the adolescent may
hold the cognition that because his girlfriend
dumped him, he is "no longer loveable"
and will be "incapable of having another
relationship." Or, the belief may be more
evaluative in nature, as he may be convinced that
because of the breakup, "he is a bad person
and a loser." One of the primary differences
between REBT and other CBT models is the idea
that the beliefs are not just irrational, but
also evaluative in nature. Therefore, with a suicidal
adolescent, it is imperative to not only identify
the irrational beliefs, but also to determine
the evaluative attributes of these beliefs. In
this particular example, the irrational belief
may be clear to the therapist; however, the "I
am a loser because she dumped me" may not
be as identifiable to the student. "C,"
according to Dryden (1995), is the adolescent's
behavioral and/or emotional consequence
of B (irrational beliefs). Consistent with the
example of the male adolescent being dumped by
his girlfriend, he may become depressed, angry,
or in this case suicidal. As a clinician, it is
also imperative to be cognizant of the affective
history of the student as well as the other risk
factors associated with suicide. The clear advantage
of REBT is the ability to link the displayed emotion
to the belief and then to the activating event.
With suicidal adolescents, the model is easy to
understand and provides a linear model that is
easy to understand by both the clinician and the
student. "D" stands for disputation.
Disputation is a method of directly challenging
the adolescent's irrational beliefs (B), by requesting
for empirical evidence that he is a loser or he
will be unable to have another relationship. Inherent
within disputation is the idea of pragmatic empiricism.
Here the therapist attempts to help the adolescent
identify his irrationality surrounding the breakup
as well as the idea of killing himself. I use
the term "pragmatic," because disputation
is direct and easy to comprehend, which is especially
important for children and/or adolescents. For
example, the therapist may ask the adolescent
what evidence exists that suggests he is a loser.
In addition, disputing the act of suicide would
be paramount in this particular circumstance.
A possible method of disputing the idea of suicide
would be to employ a didactic disputation strategy
(Walden et al. 1980). According to Walden et al.
(1980), "a second set of cognitive disputation
strategies are didactic, including the use of
mini-lectures, analogies, and parables. Lectures,
as we suggested earlier, are best kept brief and
may be useful when new ideas are being presented
to the client (p. 163)." The lecture might
revolve around suicide and the repercussions that
typically occur when someone suicides. Obviously,
there are other points that could be made; nevertheless,
in this situation it would be important to educate
the student about the consequences of death. Some
other possible methods of disputing suicidal ideation
may be to ask how he would develop further relationships
if he were dead. Additionally, why does he need
to have a relationship with this girl if she is
so "stupid" to dump him? It would be
important to point out that suicide is an irrational
response to a common adolescent problem and that
there are many other methods of releasing or displaying
his anger and/or sadness. Disputation is unique
to REBT and appears to be responsible for subsequent
behavioral/affective/cognitive change. It differs
from Beck's Socratic questioning, as it is more
direct, easier to follow and more developmentally
appropriate for adolescents. As Albert Ellis (1999)
stated, "...other forms of therapy may help
them feel better, but not get better. The goal
is to get better rather than feel better. This
is the goal of REBT (Lecture, 1999)." This
quote is extremely applicable to a suicidal adolescent,
as feeling better may not prevent suicide, yet
getting better, I believe, would. The final element
is "E," which stands for the effects
or consequences of D. While the literature is
equivocal regarding the clinical predictors of
suicide, upon psychological autopsies, hopelessness
has been identified as a common ingredient in
many successful suicides (Ellis & Newman,
1996). The utilization of disputation is particularly
important in this instance, as hopelessness can
be easily disputed.
According to Jamison (1999), "in short, when
people are suicidal, their thinking is paralyzed,
their options appear spare or nonexistent, their
mood is despairing, and hopelessness permeates
their entire mental domain (p. 93)." Therefore,
a possible disputation would be to point out to
the adolescent that he is in fact hopeful and
this particular event is simply a roadblock to
bigger and better things. A therapist could empirically
demonstrate to the adolescent that he would be
missed if he decided to suicide by assembling
a group of teachers, friends and family members
who would corroborate the therapist's didactic
disputation. These individuals could also confirm
that he is likeable person who would be missed
if he decided to kill himself. While there is
insufficient research on REBT and its application
to suicidal adolescents, one study conducted by
Woods et al. (1991) found that adolescents contemplating
suicide were the result of beliefs and/or irrational
cognitions (originating with "B.")
Strengths and weaknesses of REBT with suicidal
adolescents
Some of the potential strengths of REBT and its
application to suicidal youths would be its simplicity.
REBT seems to be a model which takes into consideration,
developmental levels - an important ingredient
when working with teenagers. REBT, in some respect,
may not seem like psychotherapy from the teenager's
perspective, due to its direct approach, didactic
style, and reliance on empiricism. Where other
models of therapy come across as mysterious and
intimidating to teenagers, REBT is exactly the
opposite.
Another strength of REBT, particularly for adolescents,
is its absence of moral and/or judgmental perspective.
For example, if a teenager commits a crime, the
expectation would be "you are a bad person."
An REBT therapist, on the other hand, would most
likely say, "you did commit a crime, yet
this does not mean you are a bad person."
This approach can be very reassuring to a teenager
who is so accustomed to being judged for what
they do, rather than for who they are. According
to Boyd and Grieger (1986). "…RET is hypothesized
to exceed the effectiveness of other cognitive-behavioral
treatments by virtue of promoting unconditional
self-acceptance and reducing ‘secondary problems'
such as self-criticism about having problems (p.
146-161)." Finally, REBT for an adolescent
who may be contemplating suicide is logical, pragmatic
and employs techniques which are developmentally
congruent with the adolescent. While there are
many potential strengths to REBT, unfortunately
there do exist a few drawbacks.
Weinrach (1990) has indicated that REBT has the
capability of rubbing individuals the wrong way.
Another criticism, or to be more accurate, a misconception
regarding REBT, is its failure to discuss the
emotionality aspects of emotional disturbances
(Garcia, 1977 ; Satzberg, 1979). REBT has also
been lambasted for being a model for tough-minded
individuals. According to Ziegler (1990), "…the
counseling profession attracts primarily Tender-Minded
students, people who are warm, sensitive, and
caring. Tender-Minded counseling students are
often threatened or alienated by a theory that
espouses, life is often unfair." Admittedly,
with a suicidal adolescent, the idea that life
is often unfair may not be the message you want
to send to someone who is holding the belief that
life "sucks." In A New Guide to Rational
Living, Ellis (1961) corroborates this idea that
he/she has a right to decide what to do with his/her
life. Surprisingly, Ellis (1961) suggests that
one address suicide forthrightly and also with
the addition of what Ellis refers to as causal
humor. This type of approach may or may not be
effective with adolescents. Yet, some may suggest
it lacks the necessary degree of empathy to efficiently
work with suicidal patients.
Review of Outcome Studies on REBT
As stated earlier, the literature is not replete
regarding the application of REBT to suicidal
adolescents. Woods et al. (1991), which analyzed
the cognitive variables correlated to the contemplation
of suicide among adolescents, found that suicidal
ideation and emotional disturbance were associated
with irrational beliefs. Woods et. al, (1991)
also found that "these young people are emotionally
distressed to the point of contemplating suicide,
not because of the A conditions frequently cited
by research in the sociological model such as
poverty, poor academic performance, unemployment
and divorce, nor by the A conditions in the second
part of a double-order problem, but by the B cognitions
reflecting the way they view themselves, others,
and the world in which they live or may live"
(p. 39-40). However, based on my review of the
literature, there was little empirical research
regarding the actual application of REBT to individuals
contemplating suicide.
Nonetheless, REBT has been shown to be an effective
treatment with many psychiatric conditions. In
addition, the application of REBT has held its
own in psychotherapy outcome studies (Haaga &
Davison, 1989). More importantly, REBT has been
deemed to be effective as to the prevention of
psychopathology. Maultsby et al., (1974) conducted
a study whereby they assembled two groups of emotionally
disturbed of high school students, one control
group (no rational-emotive course), and one group
who received rational-emotive course. Both groups
were given several personality inventories as
well as the Maultsby Common Trait Inventory (1974).
Data from this study indicated that the group
who received the rational-emotive course achieved
positive results (Maultsby et al. 1974). Results
suggested that REBT can be a useful therapy in
the prevention of psychopathology. Clearly, the
prevention component of REBT can and should be
applied to adolescent suicide and deserves further
investigation. While the effectiveness of REBT
appears to be unequivocal, further study will
undoubtedly produce research opposing such a treatment
modality. However, according to Solomon and Haaga
(1995), "we know that not everyone responds
favorably to specialized REBT."
Conclusion
Based on statistics produced by the National Institute
of Mental Health (1996), the ninth leading cause
of death in the U.S. was suicide. Among adolescents
(15-19), the numbers are shocking, as the ration
was 9.7/100,000. Keeping in mind these statistics,
it becomes paramount that all CBT models start
to aggressively address this clinical conundrum.
As stated earlier, although there is a dearth
of research pertaining to the risk factors and
psychiatric comorbidity pertaining to suicide,
the actual application of a particular CBT model
appears to have been omitted. Admittedly, this
paper was not intended to be a research-oriented
paper; however, it is crucial to point out that
there was very little research regarding REBT
and its application to suicidal adolescents. Based
on the REBT outcome studies, there appears to
be an over-identification with conduct disorders,
while, unconsciously, neglecting one of the leading
killers of our youth - suicide. As a result, the
goal of every CBT and hybrid CBT model should
be to conduct rigorous research to effectively
combat this silent killer.
References
Boyd, J., &
Grieger,R.M. (1986). Self-acceptance problems.
In A. Ellis & R.M. Grieger (Eds.), Handbook
of rational-emotive therapy (pp. 146-161). New
York: Springer.
Dryden, W. (1995). Brief Rational-Emotive Behaviour
Therapy. New York: John Wiley & Sons.
Ellis, A. (1961). A New Guide to Rational Living.
California: Wilshire Book Company.
Ellis, A, & Bernard, E.M. (1983). An overview
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Rational-emotive approaches to the problems
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Ellis, A. (1999). Working with difficult adolesecents.
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of Osteopathic Medicine, Philadelphia, PA.
Ellis, A. & MacLaren, C. (1998). Rational-emotive
behavior therapy: A therapist's guide. California:
Impact Publishers.
Garcia, E.J. (1977). Working on the E in RET.
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Jamison, R.K. (1999). Night Falls Fast: understanding
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Walen, R.S; DiGisuppee, R; & Dryden, W.
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