Rational Emotive Behavior Therapy (REBT) and its application to Suicidal Adolescents

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

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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.

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Maultsby, M., Kniping, P., & Carpenter, L. (1974). Teaching self-help in the classroom with rational self-counseling. Journal of School Health, 44, 445-448.

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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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