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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
of rational-emotive approaches to the problems
of childhood. In A. Ellis & M. Bernard
(Eds.), Rational-emotive approaches to the
problems of childhood, (pp. 1-43). New York:
Plenum Press.
Ellis, A. (1999). Working with difficult adolesecents.
Symposium conducted at the Philadelphia College
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.
In J.L. Wolfe & E. Brand (Eds.), Twenty
years of rational-emotive therapy (pp72-87).
New York; Institute for Rational Living.
Haaga, D.A., & Davison, G.C. (1989). Outcome
studies of rational-emotive therapy. In M.E.
Bernard & R. DiGiuseppe (Eds.), Inside
rational-emotive therapy: A critical apprasial
of the theory and therapy of Albert Ellis
(pp. 155-197). San Diego CA: Academic Press.
Jamison, R.K. (1999). Night Falls Fast: understanding
suicide. New York: Alfred Knoff.
Maultsby, M., Kniping, P., & Carpenter,
L. (1974). Teaching self-help in the classroom
with rational self-counseling. Journal of
School Health, 44, 445-448.
Saltzberg, L. (1979). The E in RET stands
for emotive. Psychology, 16, 51-54.
Solomon, A. & Haaga, F.A. (1995). Rational
emotive behavior research: What we know and
what we need to know. Journal of Rational-Emotive
and Cognitive Behavior Therapy, 179-191.
Walen, R.S; DiGisuppee, R; & Dryden, W.
(1980). A Practitioner's Guide to Rational-Emotive
Therapy. New York: Oxford University Press.
Weinrach, S.G. (1990, June). Obstacles to
a wider acceptance of RET. Paper presented
at the World Congress on mental health counseling/35th
anniversary conference on Rational-emotive
therapy, Keystone, CO.
Woods, J.P; Silverman, S.E; Gentitini, M.J;
Cunningham, K; & Grieger, M.R. (1991).
Cognitive variables related to suicidal contemplation
in adolescents with implications for long-range
prevention. Journal of Rational-Emotive &
Cognitive Behavior Therapy, 9, 215-245.
Ziegler, D. (1990, June). Obstacles to a wider
acceptance of RET. Paper presented at the
World Congress on mental health counseling/35th
anniversary conference on Rational-Emotive
therapy, Keystone, CO.
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