Chapter 6: Anxiety
Coping with Anxiety and Depression
- Take a time-out. Practice yoga, listen to music, meditate, get a massage, or learn relaxation techniques. Stepping back from the problem helps clear your head.
- Eat well-balanced meals. Do not skip any meals. Do keep healthful, energy-boosting snacks on hand.
- Limit alcohol and caffeine, which can aggravate anxiety and trigger panic attacks.
- Get enough sleep. When stressed, your body needs additional sleep and rest.
- Exercise daily to help you feel good and maintain your health. Check out the fitness tips below.
- Take deep breaths. Inhale and exhale slowly.
- Count to 10 slowly. Repeat, and count to 20 if necessary.
- Do your best. Instead of aiming for perfection, which isn’t possible, be proud of however close you get.
- Accept that you cannot control everything. Put your stress in perspective: Is it really as bad as you think?
- Welcome humor. A good laugh goes a long way.
- Maintain a positive attitude. Make an effort to replace negative thoughts with positive ones.
- Get involved. Volunteer or find another way to be active in your community, which creates a support network and gives you a break from everyday stress.
- Learn what triggers your anxiety. Is it work, family, school, or something else you can identify? Write in a journal when you’re feeling stressed or anxious, and look for a pattern.
- Talk to someone. Tell friends and family you’re feeling overwhelmed, and let them know how they can help you. Talk to a physician or therapist for professional help.
Fitness Tips: Stay Healthy, Manage Stress
For the biggest benefits of exercise, try to include at least 2½ hours of moderate-intensity physical activity (e.g. brisk walking) each week, 1¼ hours of a vigorous-intensity activity (such as jogging or swimming laps), or a combination of the two.
- 5 X 30: Jog, walk, bike, or dance three to five times a week for 30 minutes.
- Set small daily goals and aim for daily consistency rather than perfect workouts. It’s better to walk every day for 15-20 minutes than to wait until the weekend for a three-hour fitness marathon. Lots of scientific data suggests that frequency is most important.
- Find forms of exercise that are fun or enjoyable. Extroverted people often like classes and group activities. People who are more introverted often prefer solo pursuits.
- Distract yourself with an iPod or other portable media player to download audiobooks, podcasts, or music. Many people find it’s more fun to exercise while listening to something they enjoy.
- Recruit an “exercise buddy.” It’s often easier to stick to your exercise routine when you have to stay committed to a friend, partner, or colleague.
- Be patient when you start a new exercise program. Most sedentary people require about four to eight weeks to feel coordinated and sufficiently in shape so that exercise feels easier.
Rational Emotive Behavior Therapy
Developed by Albert Ellis in the mid-1950s, Rational Emotive Behaviour Therapy (REBT) was the first of the cognitive behaviour therapies (CBT) and continues to be one of the major CBT approaches (Bond & Dryden, 2000). After practicing psychoanalysis with Sigmund Freud, Ellis came to see flaws with his approach. Many of the answers he was looking for came from philosophy, an interest from his youth. He found that contemporary theories complimented[spelling?], and worked well with, theories from philosophers from the past (Ellis & Joffe Ellis, 2011).
Anxiety, panic, depression, and fear observed as avoidance, are all emotions often requiring professional therapy[Rewrite to improve clarity]. In dealing with these emotions, REBT teaches that, although almost everyone wants happiness, we readily counteract efforts to reach our goals with our own thoughts and perceptions. During the process of REBT clients learn about the interactional relationship between thoughts, behaviour, and emotions. To prevent detrimental emotional effects, clients learn new ways to view and respond to life’s challenges. REBT therapy involves many different techniques and may also include homework assignments. With hard work and practice, REBT promises long-term emotional change.
Foundational theories and principles
Some of the historical figures that provided inspiration to Ellis when developing REBT include:
Buddha – The Buddha used a similar active-directive style with his followers in order to help them learn to question their thoughts and emotions. When their current thinking was not effective, they were asked to consider opening up to different ways of thinking and work hard to change these habits. The Buddhist perspective views life to be rooted in suffering and this suffering is caused by cravings or needs. It is believed that relief from suffering can only be gained by ending these urges and accepting what is apparent. This can be compared to REBT teaching the recognition of irrational beliefs in order to relieve emotional distress (Christopher, 2003).
Epictetus – Epictetus’ statement “Men are not disturbed by things but by the view they take of them” (Ellis & Joffe Ellis, 2011, p. 27) is often quoted by Ellis. The power of thought over feelings or emotions, central to REBT, can be seen in this statement. Epictetus was a Roman Stoic philosopher. His accepting and unangry philosophies are often used as part of REBT therapy (Ellis & Joffe Ellis, 2011).
Other historical figures noted by Ellis to have influenced the creation of REBT include Marcus Aurelius, Confucius, Lao Tzu, Socrates, Epicurus, Seneca and Emerson (Ellis & Joffe Ellis, 2011)
REBT also has influences from many contemporary perspectives including the psychotherapist Alfred Adler and Freud. Constructivism is an idea introduced by George Kelly with his personal construct theory in 1955. Constructivism claims that a person has the ability to construct their own reality by controlling their thoughts, feelings. and actions (McWilliams, 2016). This suggests that emotional difficulties can be caused by one’s own thoughts, an idea central to REBT.
Ellis had a great deal of interest in the work of John B Watson who founded Behaviorism. Although Watson rejected the idea of thoughts and introspection being central to emotional difficulties, he provided Ellis with information and understandings contributing to REBT. Ellis found great value in Watson’s insistence on an empirical approach to achieving definitive outcomes (Carpintero, 2004).
Over the years of gathering this information Ellis learned that people have more control of their emotions than they may realise. REBT holds that people are the main contributors to their own emotional distress due to their thoughts. REBT claims that people can counteract emotional distress by learning to observe their thoughts and working on changing problematic thinking (Ellis, 1990).
Life provides us with a variety of experiences, some we look forward to and enjoy, some are neutral and others are perceived as activating events (A). It is these events which are often viewed as the cause of a person’s emotional disturbance. REBT holds that it is not the situation or event causing emotional problems. It asserts that people mainly cause the difficulties they experience with self-disturbing beliefs (B) about the event, resulting in the difficult emotional consequence (C). Therefore, contrary to traditional understanding where A determines C, the combination of both A and B determines the resulting emotional distress at C.
Rational and irrational thoughts
It is claimed that if a difficult situation should arise, a person thinking rationally will experience healthy negative emotions like sadness, remorse and disappointment. However, a person thinking in irrational ways will experience unhealthy negative emotions like depression, guilt and shame. When As are viewed negatively and perceived in a rational manner a person will think along these lines, “I don’t like As and I wish they didn’t happen but they do and I will deal with it”. This would enable the person to deal with the event. If, on the other hand, the person was to be irrational about it they may think, “This A is terrible and I can’t stand it!” In this circumstance unhealthy negative emotions will likely result. (Ellis & Joffe Ellis, 2011). See Table 1 for further comparison of rational and irrational thoughts.
Comparison of Rational and Irrational Thoughts as Proposed by REBT
|Rational thoughts||Irrational thoughts|
|Founded in science
Assessed with good reason
Claim a preference for things to be the way the person wants, not demanding it
Is forgiving of self, others and life
Has a high level of tolerance and acceptance
Results in appropriate and healthy emotions (Dryden, 2010).
|Uses words like should, must and ought
When things go wrong it is a catastrophe, awful or exaggerated
Has a low tolerance of frustration
Emotional results are unhealthy and debilitating (Dryden, 2010).
REBT theory states that irrational beliefs fall into four main categories:
- Low frustration tolerance
- Global self-downing/evaluation
- Awfulising/catastrophising (Szentagotai, Lupu, & Cosman, 2008)
Interconnectedness of thoughts, emotions and behaviour
Another principle of REBT is the interconnectedness of our thoughts, emotions and behaviour. It is believed that thoughts, emotions, and behaviour are all interrelated contributions to both B (beliefs) and C (consequence), thus determining a person’s healthy or unhealthy emotional experience.
Musturbatory beliefs and the three basic musts
Musts, shoulds, and oughts are often part of irrational thinking. REBT hypothesises that people frequently learn to become musturbators from significant others like parents, teachers, friends, and other highly regarded social acquaintances. Perhaps even more problematic is the innate tendency that people have to want more than they have, increasing that want to must have. REBT aims to prevent clients using three basic musts as it is believed they result in emotional difficulties. Use of the word must is to be avoided in contexts such as “I must always perform well or else I am no good”, “others must treat me well or they are no good” and “the world or life must always treat me well or life is no good”.
Each of these uses of the word must will contribute to specific emotional problems. “I must always, perform well or else I am no good” is believed to result in anxiety, depression, worthlessness, despair, shame and guilt. “Others must treat me well or they are no good” is thought to cause anger, vindictiveness, rage, passive aggression, and violence. “The world or life must always treat me well or life is no good” will leave the person experiencing frustration, intolerance, self-pity, procrastination, and depression (Ellis, 1999).
Meta-emotional problems (emotional disturbance about emotional disturbance)
When a person has an uncomfortable emotional response to an activating event this is considered the primary experience. Commonly referred to as secondary emotional problems, meta-emotional problems refer to detrimental psychological behaviour in response to the primary experience. This experience is a magnification of the primary experience due to the focus on, and response to, the primary emotion. This causes the person to experience the negative emotion in an even more intense manner. Some examples are experiencing anxiety about being anxious, being depressed about being depressed, putting yourself down about putting yourself down (Dryden & Neenan, 2004).
REBT is multi-modal, and as such, has integrated aspects from cognitive, emotive, and behavioural therapies. One of the main aims is for clients to gain unconditional self-acceptance and to become self-sufficient, not relying on the psychotherapist and needing to return to therapy for the same problem. It also recommends that a person live with humour and a healthy perspective. A person taking themselves and others too seriously is seen to lead to detrimental thinking causing emotional discomfort. As such, REBT uses a variety of techniques and often these are aimed at lightening the mood, including humorous songs, and joking around during a session (Ellis & Joffe Ellis, 2011).
Due to the detrimental effects of musturbatory beliefs, REBT teaches that one of the main contributors to emotional disturbance is a lack of self-acceptance, other-acceptance, and life-acceptance. Clients are taught to consistently aim to unconditionally accept themselves, others, and life, especially during difficult times. Examples of opportunities to practice this outside the clinic include: for the self, when one makes a mistake; for others, when a person does something to you that you consider to be disrespectful; towards life, such as rain on your wedding day.
During therapy clients are taught the detrimental effect of inappropriate beliefs or opinions about the A. When concluding a session clients are often asked to partake in homework exercises related to ABC theory. To solidify their understanding, clients are often asked to write up and label the ABC specifics about events that happen in their lives during the time between sessions. This labelling includes all facets of the ABC with particular focus on the B. Labelling the B involves clients being required to recognise the beliefs to be rational or irrational (Rait, Monsen, & Squires, 2010).
One of the most effective techniques of REBT is the D – disputing, of ABC theory. As the REBT psychotherapist is considered to be an expert, it is thought appropriate for them to dispute the irrational beliefs of clients. This is done in a considerate but definite manner so as to not leave clients with any doubt about the need to change their way of thinking. The final aspect of the ABC theory is the E – effective new philosophies. During REBT, clients learn to view aspects of life in different ways to those which have been contributing to their emotional difficulties (Ellis, 1974).
ABC theory provides the foundation for some of the most effective psychotherapeutic techniques. Clients are taught to find a person who displays emotional well-being, attitude, and behaviours in line with those perceived as ideal by REBT. They are then to aim to use the model’s attitudes and behaviours in their own life. Clients are also taught to research, with the aim of finding other people who have lived, or are living, in ways that emulate REBT principles. This is to expand the positive influence in the client’s life.
Furthermore, clients are to assess the cost to benefit ratio of certain situations. This is done after clients have been taught the negative impact of their detrimental behaviour and learned more beneficial habits. The loss incurred by using the newly learned skill (if any) is then compared to what may be gained. Clients are also encouraged to read books, listen to recordings, and watch videos based on REBT, other CBTs and other inspiring philosophies. This is to reinforce REBT learning. Further reinforcement is gained with clients being advised to teach others REBT habits. This can be done in circumstances focused on learning specifically or through philosophic discussion. Clients are considered to continue benefiting from REBT when they habituate to the practice of being aware of their thoughts and thinking problems through before acting. It is believed this will prevent emotional disturbance by delaying and perhaps preventing emotions being in control.
Rational emotive imagery (REI) is used in REBT to change unhealthy emotions to more healthy ones. An example of REI can be found here. REI is used to solidify understanding of one of the fundamental concepts of REBT: that all emotions are legitimate, however, some become overwhelming and certain techniques can be used to rectify problems incurred. REI involves clients vividly picturing themselves in a situation experiencing the extreme emotions. While this is happening, the therapist helps the client continue to be in the situation while changing the emotional experience to a more positive one by picturing a much more favourable negative emotional experience. In order for the response to become habit, the technique is to be practiced for at least 30 days (Ellis & Joffe Ellis, 2011).
With a similar aim, clients are also encouraged to strongly use coping statements. What makes this an emotive technique is the strength of emphasis placed on the statement. Clients are to repeat the statements whilst making them with vigor.
Some examples of statements include:
- I don’t like this but I can deal with it!
- I may make a mistake but that doesn’t ever make me a failure!
- Catastrophes do not happen to me, just inconveniences!
Role-plays are used to evoke emotions by having the person take part in an experience in which they feel uncomfortable emotions. Other people playing parts in the role-play behave in ways so as to increase this discomfort. Observers watching during the role-play critique the client’s performance and with the follow up performance all involved aim to find the “shoulds”, “musts” and “oughts” contributing to the client’s detrimental negative emotional experience (Ellis & Joffe Ellis, 2011).
Shame attacking exercises are both emotive-evocative and behavioural exercises. These exercises aim to expose the effect expectation based “shoulds” and “musts” have on the resulting shame experienced by a person. According to REBT, if a person demands they “should not” or “must not” make a mistake and then they do, shame is caused by them judging the mistake. This judgement flows on to oneself. This translation, bad mistake means bad person, is considered false. The shame attacking exercises involves doing something one would normally avoid due to it being considered shameful. While doing this, the person is told to be aware of their thoughts and emotions, being sure not to be embarrassed or put themselves down.
REBT uses some other well-known behavioural techniques such as in vivo desensitisation. This method involves a series of assignments leading to desensitisation. For example, a person with a fear of public speaking would initially be given an assignment to present a one minute speech to a close acquaintance. The next assignment would involve a longer speech. Subsequently, a speech of the same length to more people. The length and time would continue to increase until the person reaches their goal (Ellis & Joffe Ellis, 2011).
REBT holds that a person experiencing emotional difficulties is likely to have been unknowingly inducing these experiences upon themselves after gaining understandings about the world as a child. Parents, teachers, and others held in high regard will have imparted understanding with the intention of assisting the child to have a safe journey throughout life. Used in the way intended, the person would react to difficult situations in a well-balanced manner. It is thought however, that this information is distorted by the person’s self-talk.
REBT adapted principles from Alfred Korzybski, the founder of General Semantics. One of the semantics adapted includes teaching clients to cease overgeneralising with the aim of having them stop making all-encompassing judgements about the self or others and instead judge the behaviour. Additionally, Korzybski formulated the concept of secondary emotional problems, such as anxiety about being anxious and being depressed about being depressed (Ellis & Joffe Ellis, 2011). Along with Karen Horney’s ideas about the “tyranny of shoulds” (as cited in Kerr, 1984), Korzybski contributed to the notion that catastrophising and awfulising has a strong influence on the development of emotional difficulties.
According to REBT, we are naturally inclined to overgeneralise, and the influence of significant others adds to this tendency. As such, this behaviour needs to be corrected to reduce emotional difficulty. REBT teaches awareness of absolutistic thinking (must, should, hate, and horrible) and overgeneralisations as it is believed that this way of thinking can lead to the development of emotional problems when expectations are not met. Fortunately, due to the influence of constructivism, REBT teaches that we do not need to think in this way. Even if we do, this can be brought to our attention and these false premises and conclusions can be changed. REBT therapists use different techniques to do this, including education, disputing, discussion, and reasoning, to help their clients toward a more productive way of thinking.
Work and Practice
To increase the efficacy of therapy and reduce further emotional difficulties, REBT emphasises the need for clients to continue working on what they have learned in therapy. This persistence is required not only by the client but also the therapist. Therapists are to choose the most appropriate technique from the many available and persist with it. When it is believed that the most has been gained, it is suggested they try a different technique with the possibility of gaining more benefit for the client (Rait, Monsen, & Squires, 2010).
Efficacy of REBT Affecting Emotional Change
Although REBT is the first CBT and one of the most popular psychotherapeutic approaches, there has been limited research about its efficacy. Ellis and Joffe Ellis (2011) state various reasons for this. For example, The Albert Ellis institute was set up to train students in therapeutic techniques, not to conduct research. It is also suggested that the expense of good research is too high for the institute to afford. Furthermore, the mix of various cognitive, emotive, and behavioural techniques comprising REBT makes it difficult to research. Moreover, the theory of REBT is said to apply to most emotional disturbances, not one or two specifically.
Ellis and Joffe Ellis (2011) contend that, considering many REBT techniques are found within CBT, the substantial amount of research provided focusing on CBT validates REBT. For example, in order to support the clinical hypotheses of REBT, Ellis and Joffe Ellis (2011) provided the results of a comprehensive study of meta-analyses performed in relation to CBT. This meta-analysis conducted by Butler, Chapman, Forman and Beck (2006) covered 16 meta-analyses with a total of 9995 participants in 332 separate studies. The studies covered 16 diagnosed emotional disorders and provided 562 comparisons between CBT and other approaches. The results do provide support for cognitive therapy and CBT although it is suggested that future analyses need to provide more investigation into the benefit of CBT in relation to a more diverse population, specific disorders, long-term effects and more comparison to other treatments. Considering this, it does appear questionable whether Ellis and Joffe Ellis (2011) can justify the claim this study validates REBT, especially considering CBT is ultimately an approach that does differ.
Although Ellis and Joffe Ellis (2011) claim limited studies specifically focused on REBT exist, they can be found and do provide support for this approach. One example is the case study in which Wood (2017) provided REBT to an elite archer experiencing performance related anxiety before and during competition. During seven sessions the client received education about ABC theory. Her irrational beliefs were then disputed and after having learned about her irrational beliefs she was to test out her newly developed philosophy as homework. This entailed competing in competitions in which expectation to perform well was high. Self-report data showed that as her irrational belief decreased her rational beliefs improved in regularity. The results of the competitions showed improvement in scores correlating with the change in beliefs. In follow up six months later, the improved rational belief and competition scores had continued. Although it may be suggested that the self-report is questionable as the positive effects may be related to the Hawthorne effect, it is likely this athlete enjoyed positive results due to REBT.
Another study focused on the theory and mechanisms of change in relation to the effects of both REBT and CBT on major depressive disorder (MDD). Significant positive benefit was found for both approaches. Interestingly, in looking at the mechanisms of change, the researchers noted that restructuring irrational beliefs appeared to have a positive effect on depressed mood and automatic negative thought (Szentagotai, David, Lupu, & Cosman, 2008). As automatic negative thought is central to CBT this may confirm Albert Ellis’ claim that successful CBT research also confirms the efficacy of REBT. Additionally, this study was performed in Romania, thus confirming the efficacy of REBT in a cross-cultural setting and stronger results may have been found if contributing factors, like homework compliance, was considered. It should be noted that the practitioners in this study had 7 to 14 years of clinical experience, therefore, the results may not have been as promising if clinicians with less experience were used.
REBT emerged in the mid-1950s from Albert Ellis’ desire to assist people to alleviate emotional difficulties such as anxiety, panic, depression, anger, and fear. Many of the foundational REBT systems were conceived by combining what Ellis believed to be the most effective historical philosophies with favoured aspects from contemporary psychology at that time. In order to change difficult emotions, the central focus for REBT is in changing thoughts which are believed to be a strong contributor to emotional difficulties that people experience.
ABC theory explains that most people believe that an activating event causes the emotional response. However, perception of the event, and therefore the emotional response, is made to be more difficult by the person’s thoughts about the event. Additionally, REBT asserts that thoughts, emotions, and behaviour are all interconnected. Therefore a change in one will affect the others. Considering this, REBT asserts that if one profoundly changes irrational thoughts it will have a profound effect on behaviour and emotions.
Due to the combination of different perspectives used to create REBT, therapy includes a wide variety of techniques and considerations. In therapy, clients are taught ABC theory with the aim of bringing their attention to the impact of rational and irrational thinking. Therapy includes cognitive, emotive, and behavioural techniques, humour and bringing awareness to use of detrimental semantics. In order to prevent inevitable negative life experiences resulting in emotional difficulties an REBT therapist uses these techniques to teach clients to accept themselves, others, and life. As part of this, the therapist disputes clients’ irrational beliefs and teaches more rational ways of thinking. Therapy also includes homework assignments that clients are expected to complete between sessions. Through the therapy process it is believed they will grow a new understanding of how to perceive life and all that it involves. After the experience of REBT, and by continuing with the hard work and practice REBT requires, it is considered that people will negotiate life’s inevitable problems without the unhealthy emotional difficulties experienced previously.