Universitatea Babes-Bolyai
Managing Depression Using
Rational Emotive Behavior
Therapy (REBT)
To be Used Free for Research, Educational, and Training Purposes
Acknowledgements:
This REBT manual/protocol for depression is based on the rational-emotive & cognitive-behavioral therapy (REBT/CBT) manuals, elaborated at Mount Sinai School of Medicine, USA, by a team of psychologists (Dr. Daniel David, Dr. Maria Kangas, Dr. Julie Schnur), together and under the supervision of Dr. Guy Montgomery (principal investigator, American Cancer Society grant #RSGPBCPPB-108036). The external consultant for the REBT depression manual/protocol was Dr. Raymond DiGiuseppe from St. Johns’s University & Albert Ellis Institute, USA.
To cite this REBT depression manual/protocol:
The preliminary and final Romanian versions of the REBT manual/protocol for depression were used in a randomized clinical trial in Romania:
To cite the Romanian REBT manual/protocol for depression (used in Romania):
The major handbooks and general REBT manuals that are the background of this REBT depression manual/protocol are:
Ellis, A., & Grieger, R.M. (1977). Handbook of rational-emotive therapy. New York: Springer Publishing Co.
Walen, S.R., DiGiuseppe, R., & Dryden, W. (1992). A practitioner’s guide to rational-emotive therapy (2nd ed.). New York, NY, US: Oxford University Press.
Foreword:
This REBT depression manual/protocol is an evidence-based one, tested in a randomized clinical trial investigating the relative efficacy of rational-emotive behavior therapy (REBT), cognitive therapy (CT), and pharmacotherapy (fluoxetine) in the treatment of 170 outpatients with non-psychotic major depressive disorder (David et al., 2008). Patients were randomly assigned to one of the following: 14 weeks of REBT, 14 weeks of CT, or 14 weeks of pharmacotherapy. The continuous outcome measures used were the Hamilton Rating Scale for Depression (HRSD) and the Beck Depression Inventory (BDI); the categorical measure was SCID. In the REBT condition, at 14 weeks, the response rates (HRSD<12) were 65% and the recovery rates (HRSD<7) were 45%. At six-month follow-up, the response rates (HRSD<12) were 75% and the recovery rates (HRSD<7) were 52%. No differences among treatment conditions at posttest were observed. A larger effect of REBT (significant) and CT (nonsignificant) over pharmacotherapy at 6 months follow-up was noted on the HRSD only.
REBT DEPRESSION MANUAL/PROTOCOL
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I. Therapist’s Research Guide
II. Therapist-Patient Interaction Guide
1. Aim of the REBT Depression Manual
2. Definitions (a) Depression Basics (b) What is Rational Emotive Behavior Therapy? 1) What are Cognitive Techniques? 2) What are Behavioral Techniques? 3) What are Emotive Techniques
3. Managing Depression with Cognitive Techniques: The Power of Our Thoughts (a) Relearning our A-B-Cs (b) How to Think in a More Positive and More Rational Way - The Alphabet Approach (A-B-C-D-E-F)
4. Managing Depression with Behavioral Techniques (a) Activity Scheduling/Planning (b) Distraction Techniques
5. Managing Depression with Emotive Techniques (a) Humorous Methods (b) Shame-Attacking Exercises
6. Beyond REBT Treatment
*APPENDIX (1) Study Instructions (2) Spare Copies of “Depression A-B-C-D-E-F Self Help Form” (3) Example of Scheduling Form (4) Spare Copies of “Scheduling Form” (5) Spare Copies of “Emotive Techniques-Monitoring Form” |
I. THERAPIST RESEARCH GUIDE:
1. Patients:
The present REBT manual/protocol should be used with depressed patients (e.g., who meet criteria for Major Depressive Disorder, according to the DSM-IV). In the clinical trial run based on this manual (David et al., 2008), we had some additional inclusion and exclusion criteria. Inclusion criteria included a score of at least 20 on the Beck Depression Inventory, and a score of 14 or higher on the 17-item Hamilton Rating Scale for Depression. Exclusion criteria included a number of psychiatric disorders (i.e., bipolar or psychotic subtypes of depression, panic disorder, current substance abuse, past or present schizophrenia or schizophreniform disorder, organic brain syndrome, and mental retardation). Patients who were in some concurrent form of psychotherapy, who were receiving psychotropic medication, or who needed to be hospitalized because of the imminent suicide potential or psychosis were also excluded (based on the clinical protocol of Jacobson et al., 1996).
2. REBT Intervention (20 sessions):
The treatment is based on the techniques and descriptions in the REBT manuals (Ellis & Grieger, 1977; Wallen, DiGiuseppe, & Dryden 1992). After explaining the basic rules of therapy (scheduling, confidentiality, etc.), rationale of REBT and the ADCDE model, the goals of REBT are discussed with the patients. The overall elegant REBT treatment is focused on the irrational beliefs mediating depressive symptoms: demandingness (DEM), self-downing (SD), awfulizing (AWF) and low frustration tolerance (LFT). Cognitive (i.e., disputation), behavioral and emotive techniques will be used to change the target irrational beliefs. Automatic thoughts and faulty inferences are not the focus of interventions. Also, distinctive elegant REBT strategies will be focused on: (1) reducing secondary problems; (2) promoting unconditional self-acceptance; and (3) focusing on the identification and modification of DEM as the central irrational belief involved in depression. In REBT, if DEM is not readily recognizable among the cognitions collected as homework as well as verbalizations during therapy sessions, its presence is inferred from its derivates (i.e., self-downing, awfulizing, and low frustration tolerance). The hypothesis regarding the presence of DEM is tested by asking patients about it directly [e.g., patient: “it is awful that I did not pass the exam.” (awfulizing); therapist: “it sounds like you had to pass that exam, right?” (DEM)]. However, the disputation of inferred DEM is made only if the patient accepts the clinical conceptualization including DEM.
The REBT intervention consists of a 14 weeks clinical trial [12 weeks of full treatment and 2 weeks of follow-up meetings (one meeting each week) focused on therapy termination], involving a maximum of 20 individual 50-minute therapy sessions:
Weeks 1-4 (initial phase: 2 sessions each week)
Session 1 (introduction)
o Clinical diagnosis/assessment and General clinical conceptualization
o Building a therapeutical relationship (i.e., empathy, collaboration, congruence, unconditional acceptance of patient as person)
o REBT education and Treatment expectations
o Problems list
Sessions 2-8
o Each problem from the list is approached based on the ABC(DEF) model of REBT
Weeks 5-8 (middle phase: 2 sessions each week)
Sessions 9-16
o Working toward strengthening the patients’ rational beliefs and weakening the irrational beliefs
o Encourage the patients to see the links between problems, particularly those which are characterized by common irrational beliefs
Weeks 9-12 (final phase: 1 session each week)
Sessions 17-20
o Prepare patients for the task of becoming his/her own future therapist
o Discuss dependency problems and relapse prevention
Structure of the first session:
Starting to build an emphatic and collaborative therapeutic relationship
Setting the agenda (and providing a rationale for doing so)
Doing a mood check, including objective scores
Briefly reviewing the presenting problems and obtaining an update (since evaluation)
Identifying problems and setting goals
Educating the patient about the REBT model
Eliciting the patients’ expectations for therapy
Educating the patient about her/his disorder and psychotherapy process
Setting the homework
Providing a summary and eliciting feedback
Structure of session two and beyond:
Checking and maintaining the therapeutical relationship
Brief update and check on mood (and medication, alcohol and/or drug use etc.)
Bridge from previous session
Setting the agenda
Review of homework
Discussion of issue on the agenda, setting new homework, and periodic summaries
Final summary and feedback
Fundamental aspects to follow during REBT intervention:
The cognitive conceptualization of the problem, based on the ABC model
The use of a large repertoire of cognitive, behavioral, and emotive techniques to change the irrational beliefs into rational beliefs
The steps of REBT interventions: (1) behavioral activation; (2) focus on changing specific irrational/rational beliefs; and (3) focus on changing general rational and irrational beliefs
The use of homework
A special focus on DEM, promoting unconditional self-acceptance, and reducing secondary disturbances
3. REBT Manuals for Detailed Intervention Strategies:
Ellis, A., & Grieger, R.M. (1977). Handbook of rational-emotive therapy. New York: Springer Publishing Co.
Jacobson, N.S., Dobson, K.S., Truax, P.A., Addis, M.E., Kowener, A.K., Gollan, J.K., et al. (1996). A component analysis of cognitive-behavioral treatment for depression. Journal of Consulting and Clinical Psychology, 64, 295-304.
Walen, S.R., DiGiuseppe, R., & Dryden, W. (1992). A practitioner’s guide to rational-
emotive therapy (2nd ed.). New York, NY, US: Oxford University Press.
II. THERAPIST-PATIENT INTERACTION GUIDE
1. Aim of the REBT Depression Manual:
The aim of this manual is to teach you a variety of skills to help you manage any depressive symptoms or depression-related problems you might experience. More specifically, we are going to teach you how to use Rational Emotive Behavior Therapy (REBT).
Research has found that approximately 75% of patients who undergo REBT will experience an improvement in their depression symptoms. This manual will teach you how to help yourself feel less depressed and more energetic, and to cope as best as you can with any symptoms you may experience. Research has shown that the skills we’ll teach you are helpful in managing emotional distress.
2. Definitions:
(a) Depression Basics
[This brief presentation is based on the free/public educational texts from http://www.depresion.com (© 1997-2008 GlaxoSmithKline: paragraphs 1, 3, and 4) and http://www.nimh.nih.gov/health/publications/depression-a-treatable-illness.shtml (paragraph 2)]
“Some people say that depression feels like a black curtain of despair coming down over their lives. Many of them feel like they have no energy and can’t concentrate. Others feel irritable all the time for no apparent reason. The symptoms vary from person to person, but if you feel “down” for more than two weeks, and these feelings are interfering with your daily life, you may be clinically depressed.” (GlaxoSmithKline).
“A depressive disorder is a problem that involves the body, mood, and thoughts. It affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood. It is not a sign of personal weakness or a condition that can be willed or wished away. People with a depressive illness cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people who suffer from depression.” (NIH).
“Most people who have gone through one episode of depression will, sooner or later, have another one. You may begin to feel some of the symptoms of depression several weeks before you develop a full-blown episode. Learning to recognize these early triggers or symptoms and working with your therapist will help to keep the depression from worsening.” (GlaxoSmithKline).
“Most people with depression never seek help, even though most of them will respond to treatment. Treating depression is especially important because it affects you, your family, and your work. Some people with depression try to harm themselves in the mistaken belief that the way they feel will never change. Depression is a treatable disorder.” (GlaxoSmithKline).
(b) What is Rational Emotive Behavior Therapy (REBT)?
Rational Emotive Behavior Therapy (REBT) is the first form of cognitive behavior therapy (CBT) and was created by Dr. Albert Ellis in 1955. According to the REBT model, people experience undesirable activating events, about which they have rational beliefs (RBs) and irrational beliefs (IBs). These beliefs then lead to emotional, behavioral, and cognitive consequences. Rational beliefs lead to functional consequences, while irrational beliefs lead to dysfunctional consequences. Clients who engage in REBT are encouraged to actively dispute their IBs and to assimilate more efficient, adaptive and rational beliefs, with a positive impact on their emotional, cognitive, and behavioral responses (Ellis, 1962; 1994; Walen et al., 1992). Thus, REBT is a psychological theory and a treatment consisting of a combination of three different types of techniques (cognitive, behavioral, and emotive) you can use to help yourself feel better physically and emotionally, and to engage in healthier behaviors.
(1) What are Cognitive Techniques?
(2) What are Behavioral Techniques?
(3) What are Emotive Techniques?
3. Managing Depression with Cognitive Techniques: The
Power of Our Thoughts:
(a) Re-learning our A-B-Cs:
A = Activating event or situation that we experience
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B= Beliefs or thoughts regarding the situation
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C = Consequence: How we feel or act based on these beliefs
Example 1:
Person 1: A (Activating Situation) = A friend does not return your phone call
B (Beliefs/Thoughts) = “I must have done something to upset them. I am such a horrible person.”
C (Consequence/Effect) = Anxious, upset, depressed
Person 2: A (Activating Situation) = A friend does not return your phone call
B (Beliefs/Thoughts) = “They’re probably just really busy, and haven’t had time to get back to me yet.”
C (Consequence/ Effect) = Content, neutral
(b) How to think in a more positive and more rational way - The alphabet approach (A-B-C-D-E-F):
Let’s start at the very beginning - A’s (Activating Events)
EXAMPLE: “I feel depressed because of my unsuccessful life, and wonder how I am going to get through the rest of the day.”
Before we move on to B’s, let’s first focus on C’s.
EXAMPLE: “I feel hopeless and sad, I have stopped trying to exercise, and I feel even more fatigued.”
OK, now we’ll get back to B.
o Demands - Check to see if your thoughts contain the words “must,” “should,” or “ought”. For example, you might think, “I must be able to do all of my errands today!” or, you might think “Life should be fair.”
o Awfulizing/Catastrophizing - Check to see if your thoughts involve words like “awful,” “horrible,” or “terrible.” For example, you might think, “I had to take two naps today, and that’s AWFUL! I’m usually active all day long.”
o Frustration Intolerance - Check to see if your thoughts include “I can’t stand this!” or the word “unbearable.” For example, you might think, “I can’t stand being depressed like this!”
o Self-Downing - Check to see if you’re calling yourself names, being too critical of yourself, or beating up on yourself. Also, check to see if you’re basing your self-worth on one or two minor things. For example, you might think, “I was too depressed to make dinner for my kids today. I’m an insensitive mother and a terrible person.“
o Other-Downing - Check to see if you’re being too critical of or beating up on others, or basing your entire judgment of them on one or two minor things. For example, you might think, “My husband isn’t very good at talking with me about my depression. He’s totally insensitive and useless.“
o Life-Downing - Check to see if you’re judging all of your life as bad, just because it’s not perfect. For example, you might think “Life is worthless because I feel so worn out.”
D’s - Debating your Negative Beliefs
E’s - Effective/Helpful Beliefs
F’s - New More Functional Emotions and Behaviors
§ For example, you may feel more positive (happier, calmer, more relaxed), or less strongly negative (e.g., disappointed/sad vs. depressed, annoyed vs. furious).
o Behave in a more helpful way!
§ For example, you may exercise, or socialize with friends, or pursue a hobby.
o Feel better physically!
§ For example, you might feel more energetic or have less muscle tension.
Summary
4. Managing Depression with Behavioral Techniques:
(a) Behavioral Techniques
(1) Activity Scheduling/Planning
(1) First, we recommend that you write down your weekly depression treatment sessions. When you start your depression treatment you will find that the therapy team will try to keep your weekly appointments at a regular time each week (e.g., at 10am). You will also find that your visit to the therapist’s office will take on average 50 minutes. Keep in mind when planning your day to allow extra time for traveling to and from the office.
(2) Second, we suggest that you plan to give yourself 3 daily meal breaks, for breakfast, lunch and dinner. You may also want to include several short (about 10-15 minutes) snack breaks during the day.
(3) Third, we recommend that you also slot in at least one 30-minute daily physical/recreational activity. Pick an activity that you enjoy doing, such as walking, gardening, or attending yoga classes. Previous studies have shown that it is helpful to continue to engage in at least low to moderate levels of physical/recreational activities (such as working out, walking, or even gardening) during the course of your depression treatment. This will ensure that your fitness level does not considerably decrease during the course of your treatment.
(4) Fourth, we suggest that you write down on a blank sheet of paper all the activities you would like to complete during the course of the day. Make sure to list your work activities (if you are employed or self-employed), or your regular home activities if you work from home, as well as your regular daily chores such as preparing dinner, laundry, ironing, picking up kids from school, etc.
(b) Distraction Techniques
(1) Imagining a Pleasant Image/Scene
(2) Listening to relaxing or enjoyable music tapes, CDs, videos
o You may want to listen to some of your favorite music or watch one of your favorite movies to relax you, distract you, or lift your mood.
(3) Take a short walk
o Another strategy you could use to distract yourself from unpleasant thoughts and feelings you may have is to take a stroll. If you are at work, take a brief walk around your workplace, focusing on the sights and sounds around you (e.g., pictures, music, etc.). If you are at home, take a stroll around your neighborhood, or garden. Pay close attention to the characteristics of things in your neighborhood (such as the color, shape and size of neighboring buildings; what’s on display in shop windows, etc).
(4) Visualizing a “STOP” Sign
o Try to imagine a traffic stop sign or even a ‘red light’ signal in your mind when you are feeing overwhelmed or upset by your negative thoughts and feelings, including fatigue. Follow the instructions of the stop signal by saying to yourself “stop thinking these negative unhelpful thoughts” or “stop dwelling on the negative”.
5. Managing Depression with Emotive Techniques:
Emotive techniques will help you challenge and change your negative thoughts.
(a) Humorous Methods (see http://web.utk.edu/~thompson/songs.html):
o Humorous methods encourage you to challenge and not taking your negative thoughts too seriously. The following is a rational humorous song: “When I am so Blue”, written by Dr. Albert Ellis to the tune of “The Beautiful Blue Danube” by Johann Strauss, Jr.:
When I am so blue, so blue, so blue,
I sit and I stew, I stew, I stew!
I deem it so awfully horrible
That my life is rough and scarable!
Whenever my blues are verified,
I make myself doubly terrified,
For I never choose to refuse
To be blue about my blues!
(b) Shame-Attacking Exercises
o You should deliberately seek to act “shamefully” in public in order to learn to accept yourself and to tolerate the ensuing discomfort. In order to avoid harming yourself, only minor infractions of social rules are permitted (e.g., wearing bizarre clothes designed to attract public attention, calling out the time in a crowded department store).
6. Beyond REBT Treatment:
APPENDIX (available upon request)
1. Study Instructions
2. Spare Copies of the Depression A-B-C-D-E-F Self-Help Form
3. Example of the Scheduling Form
4. Spare Copies of the Scheduling Form
5. Spare Copies of the Emotive Techniques-
Monitoring Form