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With the resurgence of interest in the self-system in the late 1970s and early
1980s (see Harter, 1983; Leahy, 1985; Suls & Greenwald, 1985) came a
notable shift from emphasis on the self as a generalized, unitary construct to
increased recognition that self-perceptions vary across the domains of one's
life (Damon & Hart, 1982; Harter, 1982, 1983; Marsh, Smith, & Barnes, 1983;
Shavelson, Hubner, & Stanton, 1976). Consistent with a multidimensional
view of self, researchers devised a new wave of domain-specific self-report
instruments to assess children's self-concept within particular content
areas, in addition to general self-worth (e.g., Harter, 1982; 1985; Marsh et
al., 1983; see Byrne, 1996; Wylie, 1989, for reviews). The psychometric
quality of these multidimensional measures has been well documented
(Byrne, 1996; Wylie, 1989), but the area is still plagued with concerns about
how to best tap children's self-perceptions and what different measures tell
us about children's self-knowledge.
To address these issues, two studies were conducted to evaluate the utility
and comparability of domain-specific evaluations of self among
preadolescent, elementary school-age children. In the first study, two of the
most widely used multidimensional measures of children's self-concept were
compared in terms of reliability, validity, and stability, as well as
correspondence across common domains. In the second study, children's
self-perceptions in four major areas (peer relations, schoolwork, appearance,
and physical/athletic ability) were further examined to determine (a) the
correspondence among various types of domain-specific, self-report
approaches (questionnaires, ratings, interview data), (b) the correspondence
between self and others' perceptions of the child's performance in those
domains, and (c) the information children report using to evaluate
themselves in each domain.
STUDY 1
In at least three studies children's responses to the SDQ-1 and the SPPC have
been compared (Byrne & Schneider, 1988; Marsh, 1990; Marsh & MacDonald-
Holmes, 1990). Across studies, the construct validity of both measures was
verified by confirmatory factor analyses. Marsh and MacDonald-Holmes
(1990) also provide support for the convergent and discriminant validity of
both instruments using multitrait, multimethod analyses and found the scales
to be comparable in terms of internal consistency (coefficient alpha = .82 to
.93 for SDQ-1 subscales, and .81 to .86 for SPPC subscales). With regard to
concurrent validity, significant correlations were found between social self-
concept on the SPPC and peer assessments of sociability/leadership (Byrne
& Schneider, 1988) and between academic self-concept on both the SDQ-1
and the SPPC and teacher evaluations of achievement (Marsh & MacDonald--
Holmes, 1990). Importantly, significant, positive correlations were observed
across the SPPC and SDQ-1 for scores in comparable domains, ranging from
.54 to .86 for Grade 5 to 8 students (Byrne & Schneider, 1988) and from .56
to .68 for Grade 5 students (Marsh & MacDonald-- Holmes, 1990).
These data support previous reports of the psychometric quality of the two
scales and further suggest that, despite format and item variations, these two
measures yield similar estimates of self-concept in specific (comparable)
domains. Study 1 is a replication and extension of these findings regarding
the comparability of the scales in a Canadian sample of fifth and sixth
graders. As in prior studies, the two instruments were compared in terms of
(a) subscale interrelations, (b) internal reliability (Cronbach a), and (c)
correspondence between scores obtained on comparable subscales.
Extending previous research, we examined the stability or test-retest
reliability of subscale scores over a 1-week period, and evaluated the
correspondence of self-reports with teacher and peer assessments in each
domain. Although peer and teacher evaluations are often used as relevant
validity criteria, such comparisons generally have not been conducted across
numerous domains.
Method
Results
Comparisons of the SDQ-1 and the SPPC were made on the basis of (a)
reliability (internal consistency, test-retest stability), (b) subscale
interrelations, and (c) validity (correlations with teacher and peer ratings).
The correspondence of the two instruments was examined through
correlations between scores obtained in comparable domains.
Discussion
Data from over 200 fifth- and sixth-grade students revealed an impressive
pattern of consistency across two of the most widely used multidimensional
measures of self-concept. Comparable estimates of internal consistency and
test-retest reliability were obtained, along with highly similar patterns of
correlations across subscales, and across evaluations of self and other. Not
surprisingly, then, self-concept scores in comparable domains were highly
correlated across the two measures. Consistent with prior studies, these data
do not favor one measure over the other, and instead support the conclusion
that the SDQ-1 and SPPC provide comparable and psychometrically similar
assessments of self-concept.
Finally, the children were asked to describe the "cues" they used to develop
their own self-appraisals, by asking them to explain "how they knew" how
competent they were in each domain. Our focus on children's views of the
"data" used to determine self-assessments constitutes a unique focus within
the literature. Previous efforts have been largely attempts to validate
statistically multidimensional and hierarchical models of the self on the basis
of responses to questionnaires. Although useful, such procedures reveal little
about how individuals (especially children) themselves form their constructs
of self within specific domains.
Method
The children participated in one group testing session and one individual
interview over a 2-3 week period (order counterbalanced across classrooms),
and were assured of the confidentiality of their responses in both sessions.
During group testing, children completed the SPPC as well as a series of
rating scales on which they evaluated participating classmates and
themselves along several dimensions (described later). Teachers were asked
to complete a similar series of ratings on participating children. During the
interview, children were asked to (a) respond to a series of open-ended
questions about themselves, (b) rate how well they perceived themselves to
perform in each of four domains, and (c) explain how they determined their
own competencies in each domain.
Children also completed a series of five peer rating scales, providing peer
assessments of overall liking or popularity (sociometric measure) and of each
participant's competence in each of four domains (schoolwork, athletic
ability, peer relations, appearance), identical to those completed for Study 1.
The sociometric measure was administered first, with the order of the
remaining four scales counterbalanced across classrooms. Children's ratings
of their own competence in each of the four domains (completed along with
peer evaluations) provided an additional index of children's self-perceptions
of competence in each domain, one embedded in a context that likely
enhanced social comparisons.
2. Tell me some things about yourself that you think are good.
3. Tell me some things about yourself that you think are not so good.
5. Tell me the things about yourself that you are not really proud of.
Next, children rated on a 10-point response wheel how well they perceived
themselves to perform in each domain. Response wheels were made from
two circles of interlocking cardboard, each a different color. On the face of
each circle were lines that create 10 equal "pie slices" and the interlocking
circles could be rotated to reveal any number of "slices" of either color. Each
colored circle was labeled with either a positive or negative self-description
for a particular domain (e.g., "I get along really well with other kids" and "I
don't get along well at all with other kids" for the peer relations domain; "I do
really well in my schoolwork" and "I don't do well at all in my schoolwork" for
the academic domain). These response wheels, easily understood by the
children, corresponded to 10-point rating scales, allowing for greater
response variability, with higher scores indicating more positive self-
perceptions. They differed from other self-ratings in that (a) they provided a
visual representation of one's self-assessments that may have been more
meaningful for some students and (b) they did not highlight social
comparison (as did self-ratings embedded in the peer evaluations). The
response wheels provided a final set of self-evaluations, completed on a
different day.
Finally, children were asked "how they could tell" if they were doing well or
not doing well in each domain, in an attempt to identify the sources of
information the children used to evaluate their performance in each domain.
Responses were recorded verbatim and later categorized in terms of the type
of "cues" used to determine their self-assessments. Six major types of cues
were described by the participants, although many of the categories only
occurred in particular domains: objective outcomes (grades, test scores,
goals, wins/losses, etc.); direct feedback from others ("__ tells me I am
good"); direct affect or liking (e.g., "They tell me that they like me");
friendship (e.g., "because I have friends"); self-observations (interpretations
of one's own behavior); and performance inferred from the behavior of others
(evaluations of self based on how one is treated by others). The latter two
categories were further divided into several subcategories. Specifically, self-
observations included (a) general self-observations (e.g., "I look at myself in
the mirror," "When I get all dressed up"); (b) self-descriptions of
psychological states (e.g., "I feel good/pretty"); (c) work-related behavior
(references to completion of work, speed of performance, neatness, etc.); (d)
ability/inability to perform tasks (e.g., "I could do it perfectly the first time I
tried"); (e) interpretations of one's own performance (references to ready
understanding, task ease/difficulty, enjoyment, etc.). Performance inferred
from the behavior of others included the subcategories of (a) general
statements (e.g., "The way teachers/coaches treat you"); (b) positive social
behaviors or absence of negative behaviors (e.g., "They invite me to parties,"
"They don't tease me," or "They choose me as captain"); (c) negative social
behaviors or absence of positive behaviors (e.g., "They never include me
when they play"); (d) shared or mutual affect/cooperation (e.g., "We laugh a
lot when we get together," "We have fun together"); (e) communication (e.g.,
"We talk to each other"); (f) intimacy/loyalty/acceptance (e.g., "I can tell my
friends anything," "I can trust her not to tell secrets"); (g) similarity/ shared
values (e.g., "We like the same things"). Unclassifiable and "don't know"
responses were coded separately (see Table 8 for a list of categories).
Interrater reliability, obtained for a random sample of 25% of the children,
was computed across categories and was consistently high across domains
(agreement = 89% for academics; 90%, peer relations; 91%, athletics; and
95%, appearance).
Most surprising were results obtained in the peer relations domain. There was
little correspondence among self-report questionnaire and selfratings and no
relationship between interview measures and self-assessments derived from
questionnaires or rating scales (see Table 5).
In clear contrast, relations between self- and other evaluations were virtually
nonexistent in the domains of peer relations and, especially, appearance. In
the social domain, the correlations between self and peer or teacher
evaluations were sometimes significant but very small in magnitude, and
almost nonexistent when parent evaluations or spontaneous self-descriptions
were considered. In the appearance domain, there were no significant
relations obtained between self- and other assessments, suggesting perhaps
that beauty is indeed in the eye of the beholder.
These results are highly similar to those reported by Marsh and his colleagues
(Marsh, 1988; Marsh & Craven, 1991). Across eight studies in which the SDQ-
1 was used to assess children's self-perceptions and a single-item rating
scale was used to assess teacher perceptions of these children, Marsh (1988)
found average self-other agreement correlations for academic, athletic, peer,
and appearance domains to be .37, .38, .29, and .16, respectively. Marsh and
Craven (1991) evaluated agreement between children's SDQ-1 subscale
scores and perceptions of teachers, mothers, and fathers. Self-other
correlations tended to be somewhat higher than those reported in Marsh
(1988) but the pattern of results was similar, with the highest agreement
observed in the academic and athletic domains and somewhat weaker
agreement observed in the peer domain. The consistency of our results with
those of previous studies supports the robustness of this differential pattern
of self-other agreement across domains.
In both the academic and athletic domains, children most often relied on
rather direct sources of information, such as that obtained from academic or
athletic outcomes including references to goals, scores, winning, losing, etc.,
in the athletic domain (mentioned by 55% of the children) and references to
grades, test scores, marks, etc., in the academic domain (mentioned by 82%
of the children). In addition, a substantial number of children relied on direct
feedback from others, with 42% and 33% of the children mentioning this
source of information in the athletic and academic domains, respectively. It is
important to recall here that in these two domains in particular, direct
feedback from others is likely to be a consistent source of information, given
our earlier findings of a rather high correspondence across teachers, parents,
and peers with regard to children's performance in these two domains.
In summary, the results of the present study suggest that the measurement
of the self remains a difficult task even when the focus is on domain-specific
assessment rather than a global or unitary construct of self. As we have
demonstrated, the correspondence among different self-perception
measures varies considerably as a function of the domain being tapped, with
a reasonable degree of coherence across self-measures observed in the
athletic domain but virtually no relationship across self-measures in the
social domain.
Further, the present results indicated that the correspondence between self
and others' perceptions also varied across domains, with significant
correlations observed between self and other assessments in the athletic and
academic domains, but little or no correlation between self and other
perceptions observed in the social and appearance domains. This pattern of
differential correspondence across domains is not readily attributable to
variations in the consistency of others' perceptions of one's competence
within domains, although the correlations obtained among others'
perceptions were slightly higher in the athletic and academic domains than in
the appearance and social domains.
In conclusion, the results of the present study suggest that the recent shift
within the self literature from more general to domain-specific
selfassessments has led to the finding that children may process information
about the self quite differently across domains. Thinking of these domains as
parallel has been primarily a matter of convenience in previous research, but
on closer inspection such an assumption breaks down. In the present study,
for example, we have demonstrated that the consistency of self-
assessments, the correspondence between self and other evaluations, and to
some extent the consistency of others' evaluation varies considerably across
domains, as do the sources of information children utilize as feedback
concerning their own performance or competence. It would be beneficial to
consider in the future the unique ways in which children process information
regarding themselves as a function of the domain assessed and the
implications of such processing differences for subsequent behavior, as well
as self-evaluation.
[Reference]
REFERENCES
[Reference]
BYRNE, B. M. (1996). Measuring self concept across the life span: Issues and
instrumentation. Washington, DC: American Psychological Association.
BYRNE, B. M., & SCHNEIDER, B. H. (1988). Perceived competence scale for
children: Testing for factorial validity and invariance across age and ability.
Applied Measurement in Education, 1, 171-187.
[Reference]
[Author Affiliation]
This research was supported by grants from the University of Waterloo and
the Social Sciences and Humanities Research Council of Canada. Portions of
this paper were presented at the University of Waterloo Conference on Child
Development, Waterloo, ON, May 1988. Some of the data were collected as
part of an unpublished undergraduate honors thesis by Vanessa Ploc, and as
a pilot study for an unpublished doctoral thesis by Dr. Annie Steinhauer. We
thank the participating staff, parents and students at Alpine, Crestview, and
Southridge public schools in Kitchener-Waterloo, ON, for their cooperation in
this research, and Vanessa Ploc and Annie Steinhauer for their assistance in
data collection.
Merrill-Palmer Quarterly, October 1999, Vol. 45, No. 4, pp. 602-623. Copyright
1999 by Wayne State University Press, Detroit, MI 48201
Copyright Wayne State University Press Oct 1999. Provided by ProQuest LLC. For permission to reuse this
article, contact Copyright Clearance Center.
With regard to sexual behavior, youth with low self-esteem are more likely
to become involved in premarital sexual relationships and teen-age
pregnancies. In turn, it has been argued that individuals with low self-
concept/self-esteem tend to be more susceptible to social influences than
those with higher self-concept/self-esteem.[12] Thus, as Hayes and
Fors[13] assert, low self-esteem could become a precipitating factor for
adoption of unhealthy behavior. By making a fervent effort to enhance
positive and realistic child self-concept/self-esteem in classrooms, health
educators may increase the likelihood that healthy behavior will be adopted
by these children. Therefore, health educators should understand the discrete
definitions of self-concept and self-esteem.
The literature offers several definitions for the terms, self-concept and self-
esteem. Some writers assert that self-esteem reflects the difference
between the ideal self (how one would like to be) and the actual self (how
one actually iS).[14, 15] Atherley[16] suggested that an individual with
substantial distance between the actual self and ideal self will develop a
negative perception of self (low self-esteem), while an individual with
modest distance between the actual self and ideal self will develop a more
positive perception of self (high self-esteem).
anxiety popularity
satisfaction (80)
(1988)appearance, peer/parent
self (76)
(1990)appearance, opposite
sex/same sex/parent
relations, honesty/
trushworthiness, emotional
self (102)
physical appearance,
behavioral conduct, global
self-worth (36)
social (100)
Table 2
Self-Esteem
academic (58)
Form AD = 40)
(1978)emotional stability,
sociability
(1977)(30)
(1988)self-worth/significance/
attractiveness/competence/
ability to satisfy
aspirations (30)
(1965)(10)
popularity, personal
security (80)
CONCLUSION
References
[2.] Emery EM, McDermott RI, Holcomb DR, Marty PJ. The relationship
between youth substance use and area-specific self-esteem. J Sch Health.
1993;63(5):224-228.
[3.] Branden N. How To Raise Your Self-Esteem. New York, NY: Bantam; 1987.
[4.] Giblin PT, Poland ML, Ager PD. Clinical applications of self-esteem and
locus of control to adolescent health. J Adol Health Care. 1988;9:1-14.
[5.] Beane JA, Lipka RP. Self-Concept, Self-Esteem and the Curriculum.
Newton, Mass: Allyn and Bacon, Inc; 1984.
[8.] Miller RL. Positive self-esteem and alcohol/drug related attitudes among
school children. J Alc Drug Educ. 1988;33(3):26-31.
[9.] Young MI, Werch CE, Bakema D. Area specific self-esteem scales and
substance use among elementary and middle school children. J Sch Health.
1989;59(6):251-254.
[11.] Miller BC, Christensen RB, Olsen TD. Adolescent self-esteem in relation
to sexual altitudes end behavior. Youth & Soc. 1987;19(1):93-111.
[13.] Hays DM, Fors SW. Self-esteem and health instruction: Challenges for
curriculum development. J Sch Health. 1990;60(5):208-211.
[14.] Brooks RB. Self-esteem during the school years: Its normal
development and hazardous decline. Pediatr Clin North Am. 1992;39:517-
550.
COPYRIGHT 1997 American School Health Association. This material is published under license from the
publisher through the Gale Group, Farmington Hills, Michigan. All inquiries regarding rights should be
directed to the Gale Group. For permission to reuse this article, contact Copyright Clearance Center.
Rational-Emotive-Behavior Therapy: A Training
Manual
From:
Journal of Cognitive Psychotherapy
Date:
January 1, 2000
Author:
Dowd, E Thomas
More results for:
REBT
http://www.highbeam.com/doc/1P3-
1474560991.html
Rational-Emotive-Behavior Therapy: A Training Manual Windy Dryden. New
York: Springer Publishing (www.springerpub.com). 1999, 292 pp., $42.95
(hardcover).
Other than The Great Albert himself, I know of no one as prolific in writing
about Rational-Emotive-Behavior Therapy (REBT) as Windy Dryden. His
output has been truly prodigious and, in the main, quite informative.
His latest book is a prime example. What Dr. Dryden has done is to write a
book that attempts to recreate the atmosphere of the many training sessions
he has conducted around the world over the years. It's an ambitious project
but is largely achieved. His attention to detail in those workshops must be
incredible because this is one of the best organized and detailed books I have
ever read.
The theory aspects are familiar to anyone who has read Albert Ellis's writings
over the years. They include taking responsibility for your own disturbance
and the central place of disputing irrational thoughts in the practice of REBT.
But there are some different nuances. The number of irrational ideas seem
now to have been reduced to four (from the original 12 or 13): Musts,
Awfulizing, Low frustration tolerance, and Self/other downing. Furthermore,
there are three arguments (or methods of disputation) that Dryden uses.
These are: Empirical arguments (looking for empirical evidence that confirms
or disconfirms the client's irrational beliefs), Logical arguments (examining
whether or not the client's beliefs, are logical), and Pragmatic arguments (do
the irrational beliefs get clients what they want). Furthermore, as an example
of the tight and detailed logic of this book, Dryden recommends that the
therapist use one type of argument consistently before shifting to another,
rather than constantly shifting. It is this extreme attention to detail that
makes this book especially noteworthy.
Many of the units go beyond REBT and discuss and illustrate methods and
techniques that are common to all forms of psychotherapy. These include The
Core Conditions (Unit 5) and Therapeutic Style (Unit 6). Throughout the book,
in fact, Dryden consistently refers to writers in other traditions, such as Carl
Rogers and Edward Bordin, thus demonstrating that he is aware of the larger
therapeutic literature.
In reading this book, I was struck by how close the practice of REBT is in
many ways to that of Beck's Cognitive Therapy. But there are differences that
may be mostly stylistic. For example, both ostensibly use Socratic
Questioning. But the examples of this technique found in J. S. Beck (1995)
primarily involve open-ended questions designed to guide the client toward
self-discovery. By contrast, Dryden's examples of Socratic Questioning tend to
use closed-ended questions which can usually be answered by "yes" or "no."
Dryden even includes a Module (16) entitled, "Socratic Disputing of Irrational
Beliefs." Interestingly, however, the words "Socratic Disputing" do not even
appear in the index, being tacitly included under "Socratic Questioning." It is
an empirical question as to which is ultimately the more effective but I
suspect the questioning mode is, at least with most clients.
[Reference]
REFERENCES
Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford.
[Author Affiliation]
E. THOMAS DOWD
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article, contact Copyright Clearance Center
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1474559931.html
Stress Counseling: A Rational Emotive Approach Albert Ellis, Jack Gordon,
Michael Neenan, and Stephen Palmer. New York: Springer Publishing
Company, 1998, 200 pp. Softcover, $32.95 (U.S.), $36.80 (outside the U.S.).
Website: www.springerpub.com
Albert Ellis's vastly influential Rational Emotive Behavior Therapy (REBT) has
been around for some 40 years and is one of the best-known psychological
theories: Hundreds of articles and books have described REBT, and virtually
all counselors and psychologists trained in the United States have been
exposed to the theory in courses, books, and videos. This state of affairs can
constitute quite a hurdle for the aspiring REBT author: What ground is left to
cover?
The text also contains many useful tips for the beginning or advanced
counselor; for example, the authors suggest:
* warning the client that "relapses" are quite normal and part of the learning
process, and helping the client avoid self-damnation if a relapse occurs (p.
67);
Stress Counseling also offers brief but interesting suggestions for applying
REBT with specific client problems such as substance abuse, posttraumatic
stress disorder, personality disorders, and eating disorders. The final chapter
provides brief illustrations of how REBTmay be used in treating work-related
stress. Though too brief and general to serve as intervention guidelines,
these examples contain several interesting suggestions. In this regard, the
authors suggest that one may use inference chaining, or "in-session voluntary
hyperventilation" to good effect with persons who suffer from panic disorder.
Inference chaining can help such clients unearth the irrational beliefs that
lead to panic, while in-session deep-breathing can help them learn to
reattribute symptoms to rapid breathing rather than to "heart attacks" or
other feared events.
[Reference]
REFERENCES
Bernard, M. E., & Wolfe, J. (1993). The RET resource book for practitioners.
New York: Institute for Rational-Emotive Therapy.
Ellis, A., Gordon, J., Neenan, M., & Palmer, S. (1998). Stress counseling: A
Rational Emotive approach. New York: Springer Publishing Co.
Ellis, A., & Harper, R. (1975). A new guide to rational living. North Hollywood,
CA: Wilshire.
[Author Affiliation]
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article, contact Copyright Clearance Center.
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1161697701.html
This study examined the efficacy of Albert Ellis' Rational Emotive Behaviour
Therapy (REBT) in fostering emotional adjustment among Nigerian
adolescents. Fifty senior secondary school students were randomly selected
and divided equally into experimental and control groups. The experimental
group was treated with REBT twice a week for six weeks. The result indicated
that REBT effectively reduced the levels of anxiety and stress of the
adolescents. Although the experimental group's level of depression dropped,
the reduction was not statistically significant. Implications for counselling the
Nigerian adolescents includes using the REBT principles to draw up a
treatment programme for treating identified maladjusted adolescents within
the classroom and using it to manage the classroom climate in order to
facilitate the teaching/learning process.
Anxiety, depression and stress are emotional adjustment problems that affect
the adolescents and the society, which this study focuses on. The emotionally
maladjusted adolescent is an unhappy adolescent. And his problems certainly
demand attention if for no other reason at least on humanitarian grounds.
Since the dividing line between the emotionally maladjusted adolescent and
juvenile delinquent adolescent could be a very tenuous one, the former may
be considered as unidentified delinquent. Since both the maladjusted
adolescent and the juvenile delinquent are societal problems there is the
need to assist them out of their problems and make them socially accepted
members of the society. This study aims at using a clinical technique like
Rational Emotive Behaviour Therapy to assist emotionally disad vantaged
adolescents to develop adaptive behaviour within and outside the classroom.
Literature Review
Other definitions are based on social, cultural and clinical education factors.
Thus when we experience something, which makes a lasting impression on
us, the feeling we evoke is emotion. Emotions are relatively brief and they are
evoked in response to re-creation of an event that embarrassed us in the
past and in remembering such event, we are embarrassed again. The nature
of the emotion depends on the nature of the stimulus. This ranges from the
ecstasy people feel when they fall in love, through the joy people feel during
wedding to the grief people feel at funeral (Calson, 1993).
Ellis' (1962) basic assumptions about human nature are that:
4. Since human beings are verbal animals, the phrases and sentences that
we keep telling ourselves frequently are or become our thoughts and
emotions. Thus any human being who gets disturbed is telling himself a chain
of false sentences. Here again Ellis went too far in his assumption.
Internalised sentences could sometimes lead to emotion, but not all emotions
are the end products of self-talk.
Method Of Study
The experimental design adopted for this study is the Post-test-only Control
Group Design. The systematic random sampling method was used to select
twenty-five adolescents each into the experimental and control groups.
Subjects in the experimental group were treated with REBT twice a week for
six weeks with each session lasting one hour. The instrument used for the
study was the Odebunmi (19991) Anxiety, Depression and Stress scales in his
Psychological test for counselling and health management, which has a
concurrent validity of 0.50 at P <.01 level of significance.
Results
The results of the study indicated that the first hypothesis, which states that
there was no significant difference in the level of anxiety between research
participants in the experimental group and those in the control group, was
rejected (t = 2.92, P<0.05). From the inspection of the means, it was
discovered that the experimental group (M= 49.9, SD= 13.7) had a lower
level of anxiety when compared with that of the control group (M= 46.4, SD=
6.16).
The results of the study indicated that the second hypothesis, which states
that there was no significant difference in the level of depression between
research participants in the experimental group and those in the control
group, was accepted (t = 0.56, P<0.05). From the inspection of the means, it
was discovered that the experimental group (M= 46, SD= 6.16) had a similar
level of depression when compared with that of the control group (M= 45.6,
SD= 6.92).
The results of the study indicated that the third hypothesis, which states that
there was no significant difference in the level of stress between research
participants in the experimental group and those in the control group, was
rejected (t = 2.26, P<0.05). From the inspection of the means, it was
discovered that the experimental group (M= 48.2, SD= 12.6) had a lower
level of stress when compared with that of the control group (M= 45.6, SD=
5.28).
Discussion Of Results
The finding of this study indicated that there was a significant difference in
the level of anxiety between research participants in the experimental group
when compared with those in the control group. In effect, the counselling
method, namely, Rational Emotive Behaviour Therapy (REBT) employed in
the present study proved effective in reducing level of anxiety. The reason
why the treated subjects improved significantly on their level of anxiety can
be explained with the argument that anxiety, as adolescents' emotional
adjustment problem is amenable to psychological treatment. Moreover, REBT
assumes that man is uniquely rational, as well as irrational. When he is
thinking and behaving rationally, he is effective, happy and competent. The
REBT package in this study was used to make the subjects know this and
they were made to incorporate this assumption into their thinking system.
Since they accepted that their level of anxiety could be reduced when they
think logically and rationally, it is not surprising therefore that treated
subjects have lower level of anxiety than subjects in the control group.
The second finding indicated that no significant difference was found in the
level of depression between research participants in the experimental group
and those in the control group. On the basis of this finding, the claim of Ellis
that REBT produces better results when applied to clients' emotional
behaviour problems (Palmer, Dryden, Ellis and Yapp 1995) does not appear to
be supported here. The result of this present study does not suggest the
superiority of a treatment condition over a no treatment situation. The
assertion of Eysenck (1952, 1955, 1960; 1961) cited by Nwabuoku (1980)
and Adomeh (1997) over the years that counselling is not superior to a
situation were there is no treatment can be revisited here. Although more
evidence has been found by researchers in the field of counselling pointing to
the efficacy of psychotherapy (Filani, 1984; Morakinyo, 1986 and Adomeh,
1997) the result of the present study dealing on the reduction of level of
depression via REBT calls for caution. Since it is impossible to resolve the
debate philosophically, it is advisable to adopt any of the several positions
that have been vigorously advocated in this connection.
Moreover, the subjects of study were aware of their situational demands and
the need to acquire effective adjustment skills as basic requirements for full
human functioning. They were also aware that adherence to the demands of
adjustment would enable them to adapt to their environment. Such demands
require that they make a choice which would led them to a rewarding future
thus they preferred making a choice by applying REBT strategy to stressful
situations. The result is a reduction in level of stress in their lives. The finding
thus attests to that of Palmer (1992) who found that the application of
RET's A-B-C-D-E paradigm and relaxation techniques to stressful situations
proved effective stress management strategies.
[Reference]
References
Ellis, A. (1962). Reason And Emotion in Psychotherapy, New York: Lyle Stuart
Filani, T.O. In (1984). Mental Health adjustment Through Psychological
Treatment in Nigeria. Psychology For every-Day Living: A Nigerian. Journal of
Applied Psychology. 3(1)9-19.
Palmer, S., Dryden, W., Ellis, A & Yapp, R. (1995). Rational interviews, London:
Centre For Rational Emotive Behaviour Therapy.
[Author Affiliation]
Ilu O. C. Adomeh
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EFFECTIVENESS OF RATIONAL-EMOTIVE
EDUCATION: A QUANTITATIVE META-ANALYTICAL
STUDY
From:
Journal of Cognitive and Behavioral Psychotherapies
Date:
March 1, 2007
Author:
McMahon, James; Vernon, Ann; Trip, Simona
More results for:
APPLICATION OF REBT AND SELF ESTEEM
http://www.highbeam.com/doc/1P3-
1238577871.html
Abstract
INTRODUCTION
2) in the 1980s, Rational-Emotive Education (REE) was the topic for thirteen
(13) published articles, 2 book chapters, and eighteen (18) dissertations;
DiGiuseppe, Miller, and Trexler (1977) reviewed Maultsby and his other
studies (Maultsby, 1974; Maultsby, Knipping & Carpenter, 1974; Maultsby,
Costello & Carpenter) that argued that Rational-Emotive Education was an
efficient prophylactic against mental deterioration among non-clinical
populations of children and adolescents. Other studies reviewed by them
asserted that the children involved in an REE program were able to learn the
REBT assumptions, to modify their irrational beliefs, and to have more
functional emotions and behavior than they had before REE.
Watter (1988) analyzed the research that had been done after the dates of
those cited in the previous paragraph on Rational-Emotive Education. Watter
concluded that elementary school pupils who attended REE had modified
their anxiety levels, increased self-esteem, and raised low frustration
tolerance (LFT) toward high frustration tolerance (HFT). Generally, such
students became more skilled at coping with emotionally loaded situations.
Compared to an educational program based on elements of Freudian theory
as well as with a sex education program, REE was helpful for students to
decrease irrational beliefs and dysfunctional emotions.
Gossette and O'Brien (1989; followed by Gossette & O'Brien, 1993) judged
that the studies that had been conducted on REE did not offer enough data to
support the possibility of efficiency with school populations. The major effect
of REE was on irrational beliefs, as was expected. Their judgments were not
surprising because the content of irrational beliefs measuring scales was
identical with the content of the REE curriculum. Minor modifications were
found on behaviors: students with problems not covered in the curriculum
were less receptive to REE than students who at the outset reported no
problems.
DiGiuseppe and Bernard (1990) found that more then 90% of the studies
they reviewed supported REE efficiency in diminishing irrational beliefs. More
then 50% of the studies sampled recorded behavior modification, locus of
control internalization, changes for various personality styles and concerning
some development milestones. Fifty per cent of the studies surveyed by
these researchers supported anxiety levels having decreased while self-
esteem increased (which could further have supported an ipsilateral
statistical artifact in that as one score decreased another increased). The idea
that the emotional and behavior change was due to beliefs modification could
not be inferred from the results of any single study. However, REE had a
higher potential for changing adaptive functioning than for changing any
single, targeted behavior.
Hajzler and Bernard (1991) asserted that irrational beliefs decreased in 88%
of the studies they surveyed, while locus of control internalized in 71% of the
studied undertaken with students who displayed learning problems. They
reported that anxiety waned in 80% of the studies surveyed, while self-
esteem and general adaptation (functional behaviors) improved in 50% of
cases.
METHOD
Selection of Studies
The selection of studies was done by searching ERIC, EBSCO, and PsychInfo
from 1970 to 2006, using the key words rational emotive education. The
reference list of articles included in previous reviews was also used. To be
included in the meta-analysis, each study had to fulfill the following criteria:
2. at least one study group had to involve REE and that program had to be
clearly described;
4. the article had to have statistical data to support the main effects;
A total of 26 studies, which met the above criteria, were identified and
included in the present quatitative meta-analysis
Coding System
After having been selected, the studies were analyzed following these
categories of variables: independent, moderators, and dependent, using the
coding system proposed by Smith et al., (1980, as cited in Hunter & Schmidt,
1990). The independent variable was the treatment offered: Rational-Emotive
Education was compared with the baseline level, control group (e.g., no
treatment, waiting-list), placebo group, or other intervention (i.e., self-
instructional training, human relationships, experiential training, and
relaxation). Included in the moderator categories were the following
variables: age (i.e., children, adolescents, students), measures, intervention
length (i.e., short, medium, long), as well as subject diagnosis (i.e., no
problems, academic problems, behavior disorders, anxiety). The dependent
variables were: irrational beliefs, inferential beliefs (i.e., cognitive distortions -
cold cognitions), emotions, and behaviors (see David, 2003 for details).
REE was analyzed for its effect on different dependent variables. Table 1
shows the values of the effect size of REE on irrational beliefs, inferential
beliefs, emotions, and behaviors. Significant differences were found between
groups: F (3, 202)=2.85, p<.05, as REE seemed more efficient with irrational
beliefs and behavior modification. The effect size seemed powerful
concerning decrease in dysfunctional behaviors, and partially powerful with
irrational beliefs modification, and adequately powerful statistically
concerning inferential beliefs and changing emotions.
The results showed that the benefit of the REE participants maintained gains
in the follow-up phase compared with the control group and other
interventions (human relationship): d=2.69 [s.d.=2.17; 95% - (-1.56 - 6.94);
276 subjects; 9 comparisons].
An age effect was also revealed (see Table 5): REE was more efficient in
working with children and adolescents compared to working with
undergraduate or graduate students F (2, 204)=4, p<.05.
Furthermore, the age moderator effect on different dependent variable
decreased through REE (see Table 6). Even though the effect size was large
for children, no age effect was revealed for irrational beliefs F (2, 37)=2.29,
p>.05. The same pattern of results was obtained for inferential beliefs F(2,
36)=1, p>.05, emotions F(2, 59)=1.72, p>.05, and behaviors F(2 ,62)=2.46,
p>.05. The effect size was powerful for irrational beliefs and emotions
modification with children, adequate for the inferential beliefs, and low for
behaviors; however, the differences were not statistically significant (F (3,
49)=2.7, p>.05). For the adolescents, REE benefits were higher on behavior,
but again no significant differences were found between the dependent
variables (F (3, 96)=1.89, p>.05). The effect size value was adequate for
irrational beliefs, inferential beliefs, and emotions. No variation of the effect
size was recorded for young adults; the values of effect size for young adults
were close to medium (F (3, 49)=3, p>.05).
It seemed reasonable for the present writers to learn if the values of REE
effect size on the dependent variables were different in function of the
independent variables (see Table 7). As was expected, REE was more efficient
than other interventions (i.e., relaxation, human relationship, self-
instructional training, and experiential training) in irrational beliefs
modification; the effect size was large. Significant differences between
designs (e.g., REE vs baseline, REE vs control group, REE vs placebo, REE vs
other interventions) were obtained F (2, 36)=39.20, p<.01. The effect size
value was adequate when REE was compared with its baseline, or to a
control, or to placebo.
The same values were recorded for dysfunctional inferential beliefs when REE
was compared with the control and placebo groups. There were significant
differences between the four modalities of independent variables: F (3,
35)=10, p<.01; the effect size was low when REE was linked to its baseline
and other interventions.
Table 8 presents the impact of REE on irrational beliefs. A large effect size
resulted for The Idea Inventory, Children's Survey of Rational Beliefs, and The
Adulat Irrational idea. For the rest of the instruments, the effect size was
average. It therefore can be concluded that the results regarding REE
efficiency were influenced by the quality of the instruments used.
The next table (see Table 9) presents the results of REE effect on different
inferential beliefs. Locus of control is one of them, measured in all the
involved studies with Nowicki - Strickland Internal - External Control Scale.
Under the category of self-concept, self-esteem, self-description, and the
selfconcept were grouped. Personal orientation and self-control are
representatives for the third category of inferential beliefs. The forth category
is given by attributions and self-efficacy (they were variables only in one
study) Significant differences were found between inferential beliefs
categories F (3, 35)=14, p<.01. The effect size was higher for locus of control
and self-concept then for personal orientation, self-control and attributions,
self-efficacy. REE seemed to be more efficient in locus of control
internalization and a positive self-concept development.
Significant differences (see Table 10) were found for emotions F (5,
56)=32,25, p<.01. The effect size was large in modification of concern and
emotionality related to test anxiety. Average to large effect sizes were
observed in anger modification. Anxiety (i.e., test anxiety, state-trait anxiety)
decreases revealed an average effect size. REE has alower effect size in
lessening neuroticism and negative mental health indices.
The differences between the effect size of REE on different behaviors were
also significant F (6, 56)=45.03, p<.01. A very large effect size (see Table 11)
was revealed on playing hookey from school, behavioral problems, GPA, and
relationship with others. An average value of the main effect value for REE on
academic performance was measured on standardized tests, academic
interest, and achievement-motivation. The REE seemed not to be as efficient
in assertiveness modification.
[Reference]
REFERENCES
David, D., Szentagotai, A., Kallay, E., & Macavei, B. (2005). A synopsis of
rational - emotive behavior therapy; Basic fundamental and applied research.
Journal of Rational-Emotive and Cognitive-Behavior Therapy, 3, 175-221.
DiGiuseppe, A.R., Miller, J.N., & Trexler, D.L. (1977). A review of rationale
emotive psychotherapy outcome studies. The Counseling Psychologist, 7, 64-
72.
Gossette, L.R., & O'Brien, M.R. (1993). Efficacy of rational emotive therapy
with children: A critical reappraisal, Journal of Behavior Therapy and
Experimental Psychiatry, 24, 15-25.
Maultsby, C.M., Knipping, P., & Carpenter, L (1974). Teaching self help in the
classroom with rational self counseling, Journal of School Health, 44, 445-
448.
Maultsby, C.M., Costello, T.R., & Carpenter, L.L. (1976), Classroom Emotional
Education and Optimum Health. The Journal of the International Academy of
Preventive Medicine, 12, 24-31.
Buffington, P.W., & Stillwell, W.E. (1980). Self-control and affective education:
A case of omission. Elementary School Guidance and Counseling, 15, 152-
156.
Cangelosi, A., Gressard, F.C., & Mines, A.R (1980). The Effects of a Rational
Thinking Group on Self-Concepts in Adolescents. The School Counselor, 27,
357-361.
Hooper, R.S., & Layne, C.C (1985). Rational emotive as a short primary
prevention technique. Techniques, 1, 264 - 269.
Kachman, J.D., & Mazer, E.G (1990). Effects of rational emotive education on
the rationality, neuroticism and defense mechanisms of adolescents,
Adolescence, 25, 131-144.
Knaus, W.J., & Bokor, S. (1975). The effects of rational -emotive education
lessons on anxiety and self-concept in sixth grade students. Rational Living,
11, 25-28.
Jacobs, E., & Croake, J. (1976). Rational emotive theory applied to groups.
Journal of College Student Personnel, 17, 127-129.
Laconte, A.M., Shaw, D., & Dunn, I. (1993). The effects of a rational-emotive
program for high-risk middle school students, Psychology in the School, 30,
274-281.
Maultsby, C.M., Costello, T.R., & Carpenter, L.L. (1976), Classroom emotional
education and optimum health. The Journal of the International Academy of
Preventive Medicine, 12, 24-31
Morley, L.E., & Watkins, T.J. (1974). Locus of control and effectiveness of two
rational - emotive therapy styles. Rational Living, 9, 22-24.
Omizio, M.M., Cubberly, W.E., & Omizio, S.A. (1985). The effects of Rational
-Emotive Education groups on self-concept and locus of control among
learning disabled children. Exceptional Child, 32, 13- 19.
Rosenbaum, T., McMurray, E.N., & Campbell, M.I. (1991). The Effects of
rational Emotive Education on Locus of Control, Rationality and Anxiety in
Primary School Children, Australian Journal of Education, 35, 187-200.
Shannon, D.H., & Allen, W.T. (1998). The effectiveness of a REBT training
program in increasing the performance of high school students in
mathematics, Journal of Rational Emotive and Cognitive-Behavior Therapy,
16, 197-209.
Wilde, K.J. (1996). The relationship between rational thinking and intelligence
in children, Journal of Rational-Emotive and Cognitive-Behavior Therapy, 14,
187 - 192.
Wilde, K.J. (1994). The effects of the Let's get rational board game on rational
thinking, depression, and self-acceptance in adolescents. Journal of Rational-
Emotive and Cognitive-Behavior Therapy, 12, 189 - 196.
Zelie, K., Dtone, I. C., & Lehr, E. (1980). Cognitive -Behavioral Intervention in
School Discipline: A Preliminary Study. Personnel and Guidance Journal, 63,
80-83.
[Author Affiliation]
[Author Affiliation]
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ABSTRACT
During the last five decades, Rational Emotive Behavior Therapy (REBT)
(Ellis, 1955) clearly revealed its efficiency and flexibility beyond the clinical
settings. An adapted form of the clinical model in educational environment is
the Rational Emotive Behavior Education (REBE). By its structure and
strategies, REBE strongly emphasizes the prophylactic value of the entire
paradigm. In the present pilot study we addressed the matter of such an
educational program and tested its efficiency in the Romanian high schools.
We intended to decrease students' irrationality and offer them the chance to
develop a more adaptive life philosophy, by changing the way they see and
perceive things. To reach this goal, we used an experimental design with
repeated measures. The results clearly confirm our hypotheses and sustain
the possibility of achieving significant changes in the belief systems,
emotions and behaviors, by using an REBE intervention.
The basic idea of the REBT theory is that by changing one's irrational beliefs
into more flexible and rational ones, one may achieve a significant change in
the emotional and behavioral consequences, by changing them into more
adaptive ones (Davies, 2006). In a simple scheme, the ABC model can be
presented as follows (see Figure 1). For a more detailed description of the
ABC model and the REBT, see Dryden and Giuseppe (1990).
We started this study with the intent of seeing whether Rational Emotive
Behavior Education (REBE), derived from Rational Emotive Behavior Therapy
(REBT), could be used as an efficient educational counseling method within
the Romanian cultural norms. This is due to the fact that the current
Romanian undergraduate educational system either does not offer any viable
counseling method, or the presently used ones are not efficient enough
(Opre, 2006). Nevertheless, the REBE is a very useful method, because it can
be easily learned, taught, and then applied to virtually any student within and
outside the educational system. It is also very direct, time and cost-efficient,
for it takes a very short time to teach it, understand it, and then apply it in all
sorts of environments (Bernard & Ellis, 1983).
The first problem that we encountered after we had begun working with
students was their lack of familiarity with argumentative discussions and
polemics. Romanian students are usually used to obey to their teachers'
instructions, and reproduce what has been said (unconditionally accept
whatever the teachers tell them, without asking any explanations for their
unanswered questions). However, the reasons for using REBE go far beyond
this issue, because the irrational ideas that REBE attempts to change relate
precisely to many of the problems students have to deal with nowadays:
egocentrism, uncertainty, a global evaluation of themselves, in terms of the
achieved performance, exaggerating (awfullising) events, self-defeating
behaviors (Nucci, 2002). If we really want to help young adults overcome
their practical or emotional problems, one has to teach them how to
successfully change their dysfunctional thoughts and beliefs, thus changing
behaviors as well; otherwise, any prevention efforts are almost useless (Ellis,
2005).
The major aim of our study is to investigate the possible benefic effects of an
REBE intervention on 11th grader Romanian students, by changing their
irrational thinking patterns into more adaptive rational ones, thus achieving a
better emotional and overall functioning. More precisely, we intended to
evaluate the possible positive consequences of a program built on the tenets
of cognitive restructuring on emotional and behavioral experiences.
Consequently, we formulated the following hypotheses: "by applying an
REBT based intervention, participants in the experimental group would
experience lower levels of irrationality than participants in the control group";
more specifically, significantly lower levels of (1) demandingness, (2)
awfullising, (3) low frustration tolerance, and (4) self-downing.
METHOD
Participants
Materials
After the pretest phase (assessment with ABS II), we moved on to the
introductory phase, which meant presenting the students the basics of
Rational Emotive Behavior Therapy and Rational Emotive Behavior Education
(rational vs. irrational thinking styles, the ABC model, activating events,
rational vs. irrational beliefs, emotional or behavioral consequences,
functional vs. dysfunctional negative emotions, etc; for more information on
this matter, see Ellis, 1972; Ellis, 1979). After explaining and verifying their
understanding of the ABC model and the REBT foundations, we moved
further to the applications, based on several resources: Vernon's Emotional
Curriculum for Adolescents (Vernon, 1989), Bedell's Handbook for
Communication (Bedell & Lennox, 1997). The posttest (assessment with ABS
II) has been done 6 months after the intervention.
Since there have not been found any significant differences between the
experimental (1) and control (2) groups regarding the levels of different
aspects of irrationality, we have proceeded to investigate the possible effects
of the experimental intervention by conducting a paired sample t-test
regarding the posttest results (see Table 2).
As seen, only in the case of the experimental group did the different levels of
irrationality significantly lower. Demandingness has lowered significantly in
the aftermath of the REBE intervention (t = 3.07 at p<.01), as well as Low
Frustration Tolerance (t = 3.42 at p<.00), Self-downing (t = 4.20 at p<.01),
Awfulizing (t = 6.08 at p<.01). The overall level of irrationality has as well
significantly lowered as a result of this specific type of intervention (t = 5.41
at p<.01). In the case of the control group the levels of irrationality have not
significantly changed. This means that our counseling program really had a
reasonable effect.
The literature has established cut-off points for different levels and severities
of irrationality. Thus, scores on the ABS between 0-91 represent very low
levels of irrationality; between 92-107 low levels, 108-121 moderate levels,
between 122-127 high levels and between 136-288 very high levels of
irrationality (Macavei, 2002).
Since we wanted to see who would most benefit from this specific kind of
intervention, we have a-posteriory divided our experimental group into two
subgroups: those with initial (T1) ABS scores below moderate (108) - group 1,
and those with initial (T2) ABS scores above moderate (108) - group 2.
Thus, next we have proceeded to paired samples t-test for scores obtained at
T2 (see Table 3) within the experimental group, divided depending on the
initial levels of general irrationality.
Resuming, the main purpose of the present pilot study was to teach the
participants how to effectively identify and change their irrational thinking
patters so that they might develop a more adaptive life philosophy. Thus, the
intervention mostly targeted the cognitive level, mainly based on the
cognitive ABC model. The other two dimensions of intervention (emotional
and behavioral) will be addressed in a future research that will continue this
pilot study. Our future studies will focus other dimensions of functioning as
well, where changes in thinking patterns might have significant benefits (e.g.,
levels of affectivity, depression, school performance, interpersonal
relationships, etc.).
[Reference]
REFERENCES
Broder, M. S. (2001). Dr. Albert Ellis - In His Own Words - On Success. Journal
of Rational-Emotive & Cognitive-Behavior Therapy, 2, 77-88.
Dryden, W., & DiGiuseppe, R., (1990). A Primer on Rational Emotive Therapy.
Champaign, IL, Research Press.
Ellis, A., (1971). Growth Through Reason, North Hollywood, CA Wlishire Books.
Ellis, A., (1972). Emotional Education in the Classroom: The Living School.
Journal of Clinical Child Psychology, 1, 19-22.
Ellis. A. (2005). The Myth of Self Esteem: How Rational Emotive Behavior
Therapy Can Change Your Life Forever. Amherst, NY: Prometheus.
Gonzales, J.E., Nelson, J.R., Gutkin, T.B., Saunders, A. et al. (2004). Rational
Emotive Therapy with Children and Adolescents: A Meta Analysis. Journal of
Rational Emotive & Cognitive Behavior Therapy, 4, 222-236.
Hauck, P.A. (2001). When reason is not enough. Journal of Rational-Emotive &
Cognitive Behavior Therapy, 4, 245-257.
Martin, R.C. & Dahlen, E.R. (2004). Irrational Beliefs and the Experience and
Expression of Anger. Journal of Rational-Emotive & Cognitive-Behavior
Therapy, 1, 1-18.
Opre, A., & David, D. (2006). Dezvoltarea inteligent ei emot ionale prin
programe de educat ie rational-emotiva si comportamentala . Alexandru Ros
ca, 1906-1996 Omul, savantul si creatorul de scoal a . Bucures ti: Editura
Academiei Române.
Weinrach, S.G., Ellis, A., MacLaren, C. & DiGiuseppe R., (2006). Rational
emotive behavior therapy successes and failures: Eight personal
perspectives. Journal of Rational - Emotive & Cognitive - Behavior Therapy, 4,
233 - 256.
Wessler, R.A., & Wessler, R.L. (1980). The Principles And Practice Of Rational
Emotive Therapy. San Francisco: Jossey Bay.
[Author Affiliation]
[Author Affiliation]
* Corresponding author:
E-mail: sebastianvaida@psychology.ro
[Author Affiliation]
APPENDIX 1
MAIN THEMES
SELF ACCEPTANCE
Deleting the Past
What Matters to Me
Critics
Compliments
Success
EMOTIONS
INTERPERSONAL RELATIONSHIPS
APPENDIX 2
Activity Example
Procedure:
Discussion
Content Questions:
Personal Questions:
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ABSTRACT
I. INTRODUCTION
1. A Brief History
The case study research method is defined as "an empirical inquiry that
investigates a contemporary phenomenon within its real-life context, when
the boundaries between phenomenon and context are not clearly evident,
and in which multiple sources of evidence are used" (Yin, 1984, p. 23). Thus,
case study methodology uses in-depth examination of single and/or multiple
case studies, which provides a systematic way of approaching the problem,
collecting and analyzing the data, and reporting the results.
(3) When no other cases are available (i.e., critical and/or unusual cases), the
researcher is limited to case study methodology (i.e., single-case design). If
the objective is similar to that described at point 4, case study should be the
choice research methodology.
Case study is not useful in testing a theory based on verification, and then
arguing that the theory is validated. Generally, the choice for or against case
study methodology depends on the problem we have to solve. If the problem
implies knowledge based on sampling logics, case study methodology should
be avoided.
a. The research should start with the problem - the study question. The
problem can be defined as a discrepancy between an initial state (what he
have) and a final state (what we want to have). A rigorous problem will define
precisely the initial state and will specify clearly the objectives. A serious
problem is one in which the discrepancy between the initial and final states is
approachable by current methodology. For example, if my proposed final
state is to eliminate all mental disorders in the next two years, this will not be
considered a serious problem considering current knowledge in clinical
psychology and medicine.
b. The objectives and/or the hypotheses should be made clear (if they exist).
c. The next step involves defining the unit of analysis and than data
collection. It must be made clear that data collection can be guided by either
quantitative and/or qualitative methods. Data can come for various sources
and depending on the problem and objectives, it can be collected
qualitatively (e.g., by interview) and/or quantitatively (e.g., numerically).
e. In the next step, logic is used to link our results to our objectives and/or
hypotheses. This is where people who use case study methodology make
most mistakes (e.g., generalize when it is not the case). Therefore, it is
fundamental to binocularly integrate the logics and the design of the study to
avoid such errors.
II. APPLICATIONS
Case Study in Research (adapted after David & McMahon: "Clinical strategies
in cognitive behavioral therapy; a case analysis" published in the Romanian
Journal of Cognitive and Behavioral Psychotherapies, vol. 1, no. 1, September
2001, pp. 71-86; see also David, 2003; David et al., 2004; David, 2006a;
2006b). The case of "Dana" is a classic one in the Romanian clinical
literature; this is why it is presented based on its previous publications,
although the context is new (i.e., case study methodology).
1. The Problem
1.1. Introduction
Many people find the distinction among "Behavior Therapy (BT)", "Cognitive
Therapy (CT)", "Cognitive Behavior Modification (CBM)", and "Rational
Emotive Behavior Therapy (REBT)" confused and confusing (Dobson, 2001;
Lazarus, personal communication). We believe that the time has come to stop
elaborating on details regarding the various schools and systems of cognitive
behavior therapy/therapies (CBT), and (1) to focus on the science and theory
of cognitive behavior therapy; (2) to discuss treatments of choice for specific
conditions; (3) to focus on what is and what is not empirically supported; and
(4) to develop really good manuals so that experimentally oriented clinicians
can endeavor to test, repudiate or replicate particular claims and findings. We
think that all these goals can be accomplished under the umbrella of
cognitive science. Cognitive science attempts to understand the basic
mechanisms governing human mind, basic mechanisms that are important in
understanding behavior studies by other clinical and social sciences.
Cognitive science studies the foundation on which many other social and
clinical/psychological sciences stand (Anderson, 1990).
Our basic argument is that CBT should be driven by cognitive science theory
in clinical research and theory, case conceptualization, and empirically
validated treatments of choice for specific conditions. In the next section of
this article, we discuss (1) some brief considerations on cognitive science and
the theory of emotions, with implications for theoretical integration within
CBT; (2) a case conceptualization based on the theoretical considerations;
and (3) a CT strategy and an elegant REBT strategy to change the target
cognitions in order to change the emotional difficulties. The inelegant REBT
(see Ellis, 1994 for details about the distinction between elegant and
inelegant REBT) seems to be similar with CT so that such a comparison
becomes redundant. Pros and Cons for each strategy are briefly mentioned.
1.2. Cognitive science and emotional problems; A brief presentation (see also
David, 2003; David et al., 2004)
Following the previous distinction between hot and cold cognitions, according
to the appraisal theory of emotions, emotional problems will only appear in
cases 1 (distorted representation/negatively appraised) and 2 (non-distorted
representation / negatively appraised). In case 1 (distorted representation /
negatively appraised), if one changes the distorted representations (e.g., "He
hates me") into an accurate one (e.g., "He does not hate me"), one may end
up changing the negative emotion (anxiety) into a positive one (happiness).
However, the individual may still be prone to emotional problems because
the tendency to make negative appraisals (e.g., "It is awful that he hates
me") is still present. If one changes the negative appraisal (e.g., "It is awful
that he hates me") into a less personally relevant one (e.g., "It is bad that he
hates me but I can stand it"), it is probable to change the dysfunctional
emotion (anxiety) into a functional but still negative one (concern; for the
distinction between functional and dysfunctional emotions see Ellis, 1994). A
strategy that will change both distorted representation and negative
appraisal seems to be a better choice. In case 2 (non-distorted
representation/negatively appraised), the choice seems to be the change of
negative appraisal that would generate a positive (happiness) or negative
(concern) functional emotion. Another possibility is to change a non-distorted
representation (e.g., "He really hates me") into a positively distorted one (i.e.,
positive illusion: "His negative comments are a way of communicating that
he considers me a strong and reasonable person"). However, as in the first
case, in the second situation we may change both representation and
negative appraisal.
Dana is a 28 years-old physician, mother of one, who lives with her husband,
and who has been working full-time as a fellow in gastro-enterology for the
past 3 years.
Chief Complaint. Dana sought psychological treatment for panic attacks and
generalized anxiety at the end of and the beginning of 2000 (18 sessions).
Two months before treatment she had had three panic attacks and feared
having another one. She also reported: "Since about 1991, I have been
feeling nervous and excessively anxious about my life (e.g., "my future job as
a physician"), my relationships (e.g., "with colleagues and my husband") and
my significant activities (e.g., "my school performance, my doctorate"), but
right now I am much more concerned about the recent panic attacks".
History of Present Illness. In 1991, Dana moved away from home, far from
her overprotective parents, to study medicine at a prestigious university.
Starting then she began feeling helpless and she reported attacks of
excessive anxiety and "worry about everything" (emotional symptoms).
These emotional states were often associated with muscular tension, feelings
of weakness, fatigue, and sleep disturbance (physiological symptoms). She
always found it difficult to control these physical symptoms and,
consequently, she started avoiding activities that required physical effort
(behavior symptoms). She thought that her symptoms would affect her
performance at work and her value as a competent human being (cognitive
symptoms); consequently, she often felt helpless, with low self-esteem. Her
GP and then a psychiatrist prescribed her Buspar (Buspirona) (in 1993). After
several months of medical treatment, she gave it up, as it had reduced
symptoms less than she expected. The first panic attack occurred while she
was preparing for her doctoral exam about two months before our first
meeting (1999). About one month later she had another attack. At the time
of the second attack she was at home cleaning her apartment. The third
panic attack occurred just one week before our first meeting, while she was
home alone, preparing a paper for a scientific congress. Her panic symptoms
included the following: Emotional symptoms: intense fear of loosing control,
helplessness and discomfort; Cognitive symptoms: believing that she was
going to die, had heart problems, and that she was going to faint and
collapse; Behavioral symptoms: avoiding physical effort and looking for safe
places in case she fainted; Physiological symptoms: palpitations, trembling,
and chest pains. She consulted a psychiatrist regarding these symptoms, and
was prescribed XANAX just two months before our first meeting.
The major stressors in Dana's life were mainly social. She was an
overprotected child, and being far from home and from the protection of her
parents during training in medical school was the first major stressor that
might have precipitated her generalized anxiety (1991). Moreover, before
getting married (she got married in1998), Dana had hoped that her husband
would be a real support for her. She believed that he could help her to
overcome her anxiety and her "worries about everything". Unfortunately, her
husband's job was highly demanding. He was an assistant professor and a
researcher often working hard late at nights and on weekends. He was not
very involved in the household and in their child's education (the birth of
Dana's son was another stressor and opportunity for her to worry about:
"Considering that I am so busy, how will I have enough time for my son?").
Consequently, she felt overwhelmed by her life as wife, mother, physician,
and student, doing her full-time job as physician, cleaning the apartment,
cooking, taking care of her son, and preparing for her exams doctoral exams.
These were the conditions in which her first panic attacks developed (1999).
Personal and Social History. Dana was an only child. She described her father
as very rigid, controlling and concerned with the future of his daughter.
Because of his authoritative attitude she had been afraid to argue with him
or ask something from him (the same thing is true even now as an adult). She
described her mother as a warm person, highly concerned with the education
and the future of her daughter. Dana remembered that during kindergarten,
primary and secondary school she had been overprotected by her parents but
that she had not liked that attitude at all. For example, every morning they
left her at school and in the afternoon they picked her up. Because of this,
she had no opportunity to have friends and/or be with her colleagues. She
described herself as a girl (and now a woman) with very poor social and
assertiveness skills both at home and in other social situations. During high
school she started preparation for medical school. Both parents wanted her to
attend medical school. They allowed her to have a boyfriend (the relationship
was not very intense); however, they were only allowed to meet at her home
or go out for several hours in the afternoon. After starting medical school
(1991), Dana had to move to another town. During the first year (she was 18)
her parents visited regularly. They did not want her to live in a dorm with her
colleagues, so they rented an apartment where she could learn without being
disturbed by others. During her first year in medical school she started
experiencing intense signs of generalized anxiety and some symptoms of
subclinical depression. She felt alone, helpless, and started to worry about
everything (but not about the separation from her parents - this was one of
the reasons why we did not consider a diagnosis of separation anxiety!).
During her second year of study (1993) she decided to see a general
practitioner and a psychiatrist who prescribed her Buspar (Buspirona). After
several months she gave up treatment because the symptoms of generalized
anxiety persisted. Despite these symptoms she graduated medical school
successfully in 1997 and started working as a fellow in gastro-enterology. She
met her husband around the same. She described him as very bright, strong
and mature man, 15 years older than she was. They fell in love and got
married in 1998. They live in the same town where she graduated medical
school. After one year of marriage their son was born. In 1998 she started a
doctoral program in medicine. During their second year of marriage (1999)
she experienced her first panic attack. I (DD) met her in 1999 after she had
experienced three panic attacks. Beside psychotherapy, Dana took
medication (XANAX) prescribed by her psychiatrist.
Medical history. Dana had no medical problems which could influenced her
psychological functioning or the treatment process.
Mental Status Check. The patient was fully oriented with an anxious mood.
D. Strengths and assets. Dana is a bright person with a good physical health.
She loves medicine and she is very disciplined. She wants the best for her
and her family and consequently, no effort is to high to attain these goals.
She has lived with generalized anxiety for almost 7 years. The coping
mechanisms she employed during these years were: avoiding problems,
avoiding physical exercise and studying hard.
2.3. Treatment plan; A cognitive therapy perspective (by Dr. Daniel David)
A. Problems list: (1) Dana's panic attacks; (2) general feeling of worry about
everything (generalized anxiety and subclinical depression); (3) relationship
with her husband concerning the support he might offer to her (4) low
selfesteem and social and assertiveness skills.
B. Treatment goals: (1) to reduce panic attacks (including panic about panic);
(2) to reduce negative distorted thinking with impact on generalized anxiety
and subclinical depression; (3) to build assertiveness and problem solving
skills in order to improve the relationship with her husband and her ability of
solving practical problem; (4) increase social skills with impact on her
dependent personality traits.
C. Treatment plan. The treatment plan was to first reduce Dana's panic
attacks (including panic about panic) and then her generalized anxiety and
subclinical depression. We also planned to work on her assertiveness, self-
esteem, and social skills. Finally, some practical problems were approached
and a relapse prevention program was introduced.
1. The patient was taught a distraction technique for panic attacks (e.g., to
describe in detail all the objects in the room). This technique: (a) would
counter Dana's belief that she had no control over her anxiety; (b) be a useful
symptom management technique when it was difficult to challenge automatic
thoughts; and (c) be a potent demonstration of the cognitive model of
anxiety to which Dana was initially quite reluctant. She was then introduced
to voluntary hyperventilation technique. This was useful in modifying her
catastrophic interpretations of the bodily sensations she experienced during
panic attack. Controlled breathing was also introduced with the purpose of
reducing hyperventilation.
Outcome. Dana's therapy extended over 18 sessions. Six months after the
end of therapy, Dana had no recurrence of panic attacks or symptoms of
subclinical depression. However, some symptoms of generalized anxiety
persisted but they did not meet the DSM IV criteria for generalized anxiety
disorder. Dana's assertiveness and social skills improved significantly and had
a positive impact on her relationships (including with husband and parents)
and on the reduction of dependent personality characteristics. All these
results are operationalized in a single case experiment design: multiple
baselines across symptoms.
2.5. The treatment plan; An REBT strategy (by Dr. James McMahon).
An REBT treatment regimen was put into place, the process of intervention
was commented upon and acceptable to both patient and therapist. Several
issues were emphasized to her namely, that the idea was to be better not get
better, that two primary aspects on the neurotic continuum of thinking-
feeling were her tendency to exaggerate (awfulizing) and to avoid negative
emotions, thereby giving her temporary comfort but long-term misery (low
frustration tolerance). Also it was discussed with Dana how her problems
seemed to be related to demandigness oriented to her own person (e.g., "I
have to do everything at high standards") and others (e.g., "Others have to
help me"). If these demands are not attained, then she moves into self-
downing (e.g., I am weak), awfulizing (e.g., "It is awful") and low frustration
tolerance (e.g., "I cannot stand it"). Session 2-4 went to the heart of panic.
Checked was the secondary problem (panic about panic) and the irrational
beliefs involved (e.g., "I have to be in control otherwise it is awful and I
cannot stand it"; DEM, AWF and LFT). The primary emotional problem was
then focused upon (where we identified others DEM, AWF, LFT and SD).
Session 5-7 stressed self-worth issues related to generalized anxiety and
subclinical depression (e.g., stubborn refusal to judge herself, examining her
roles and how to judge them through the who/what process, rational-emotive
imagery in which she perceived herself to be in control of her own life and
that she was in charge, and disputation of other irrational beliefs). Sessions
8-12 involved further restructuring of IBs into adaptive alternatives (at
different levels of abstraction) and how to distinguish beliefs from feelings
about beliefs. She kept a log of the type of empirical, logical and pragmatic
disputations. Session 13-18 involved dealing with issues of dependency
throughout her life, looking for alternative conceptions. Some practical
problems were approached, and revisiting panic and anxiety situations was
undertaken to preclude regression.
Outcomes. Dana reported in the last session that she was free of panic
attacks, that she could distinguish rational from irrational beliefs, and that
she generally felt happy and liked herself. Regarding her own goals, she
indicated that she was generally happy but busy with her family and work,
that she judged that she could head off panic attacks in the future, and that
she was assertively negotiating home duties with her husband. The patient
and the therapist judged that she achieved good results therapeutically and
as a person.
2.6. Discussion
2.6.1. Comment upon the cognitive therapy strategy (by Dr. James
McMahon).
The work of Dr. Daniel David was generally masterful: good diagnosis, good
interventions, and the goals were attained. He used all available CBT
techniques that were appropriate by distinguishing automatic thoughts vs.
core beliefs vs. evaluative cognitions. However, I would mention that the
distinction between core beliefs (cold cognitions) and evaluative cognitions
(hot cognitions) is not always clear in cognitive therapy, although here, Dr.
David made it very clear. Also, many cognitive therapists prefer to work only
at the level of distorted cold cognitions, both surface and deep, rather than
at both cold cognitions and evaluative beliefs. In that case, the patients may
feel better but not get better. For example, they may feel better because the
activating events (e.g., "It is not true that she laughs at me") are not
dangerous, but the individual still may be prone to emotional problems
because the tendency to make negative appraisals (e.g., "It is awful when she
laughs at me") of activating events incongruent with their goals (e.g., "She
really laugh at me") is still present. However, here, Dr. David approached
correctly both types of cognitions. If there were one negative aspect, that
would be that therapy did not get to the person. Rather, therapy dealt with
symptoms, and then their causes and cure. While achieving personhood in CT
can be inferred, it can only be inferred as one of the several schemas since
the theory purports to be empirical and so deals with piece-by-piece
examples of pathology. Contradistinction, REBT theory clearly tries to
achieve fundamental philosophical change and so is person driven.
I think that Dr. McMahon's elegant REBT is really elegant: great clinical
approach! Unlike me, Dr. McMahon attacked evaluative cognitions directly. I
myself would approach evaluative cognitions, but after a careful challenging
of automatic thoughts and core beliefs. My general criticism to Dr. McMahon's
approach would be that by directly changing evaluative cognitions and
assuming that distortions are real (e.g., "Let us suppose that you are indeed
not able to work at high standards; How does this make you weak and
inadequate as a person?" or "How is this awful?", etc.) one may change a
dysfunctional emotion (anxiety) into a negative functional emotion (concern)
because automatic thoughts (e.g., "I will not be able to prepare my
presentation") and deep cold cognitions are not directly disputed in the
elegant REBT. I know that Dr. McMahon might suggest that by changing
evaluations one indirectly changes distortions too, and indeed, one may
invoke some corpus of research which supports this hypothesis (Dryden,
Ferguson, & Clark, 1989 but see Bond & Dryden, 2001). However, sometimes
distortions may gain functional autonomy from the evaluative cognitions (see
Allport's concept of "functional autonomy"); in this case the change of
evaluative cognitions might not be accompanied by a change in the
distortions. Consequently, the client may feel better (e.g., "concern" rather
than "anxious") but not achieve the best results (e.g., "relaxed", "calm" or
even "happy"). On the other hand, as Ellis repeatedly mentions, (Ellis, 1994),
not all patients may benefit directly from elegant REBT. However, in our case
the patient seems to be in a positive emotional state and thus, Dr. McMahon's
direct disputation of IBs also seemed to change cognitive distortions (i.e.,
elegant REBT). If that had not happen, I suppose that Dr. McMahon would
have forcefully disputed the distortions too (i.e., inelegant REBT). The
difference between our approaches seems to be in terms of strategy. I
started with automatic thought, core beliefs and then evaluative cognitions.
With bright clients, Dr. McMahon seems to prefer starting with evaluative
cognitions and then maybe working on distortions, if necessary (I know that if
the change of irrational beliefs was not accompanied by a change in
distorted cold cognitions, Dr. McMahon would directly examine automatic
thoughts and other distortions - personal communication). I would like to see
some research evaluating concurrently these two different cognitive
strategies. I assume that their efficacy may differ depending on the clinical
condition (e.g., the type of psychopathology, the type of client).
III. DISCUSSIONS
After a short history, this paper briefly and critically presented the
fundamentals of case study methodology. We have then exemplified, by
using the case of "Dana" from our previous publications, how it can be
employed in clinical practice. We hope that the message to take home after
reading this article is clear. Case study methodology is not rigorous or less
rigorous per se. It becomes rigorous or less rigorous depending on the type of
knowledge we want to generate in order to solve specific problems. This is
true for all the research methods. The problems which case study is best fit to
solve are those related to exploratory studies (i.e., generating new theories),
to critical, and unusual cases. It is less fit to test a theory although, if
conditions for falsifiability are met, it can be implemented with this purpose
as well. When used appropriately, case study methodology is very rigorous,
comparable with any other research method. By appropriate we mean two
things: (1) adequate to the problem it is intended to solve; and (2)
implemented at high standards in terms of internal constraints and steps that
need to be followed.
[Reference]
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Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of
depression. New York: Gilford Press.
David, D., Miclea, M., & Opre, A. (2004). The information processing approach
to the human mind: Basics and beyond. Journal of Clinical Psychology, 60,
353-369.
Dryden, W., Ferguson, J., & Clark, T. (1989). Beliefs and influences: A test of a
rationalemotive hypothesis: I. Performance in an academic seminar. Journal
of Rational- Emotive & Cognitive-Behavior Therapy, 7, 119-129
Dryden, W., & Bond, F. W. (2000). How rational beliefs and irrational beliefs
affect people's inferences: An experimental investigation. Behavioural and
Cognitive Psychotherapy, 28, 33-43.
Ellis, A. (1994). Reason and emotion in psychotherapy (re. ed.). Secaucus, NJ:
Birscj Lane.
Ingram, R. E., & Siegle, G. J. (2001). Cognition and Clinical Science: From
revolution to evolution. In K. S. Dobson (Ed.), Handbook of cognitive-
behavioral therapies. New York: Guilford Press.
Smith, C. A., Haynes, K. N., Lazarus, R. S., & Pope, L. K. (1993). In search of
the "hot" cognitions: Attributions, appraisals and their relation to emotion.
Journal of Personality and Social Psychology, 65, 916-929.
Wessler, R. A., & Wessler, R. L. (1980). The principles and practice of rational-
emotive therapy. San Francisco, CA: Jossey-Bass.
Yin, R. K. (1984). Case study research: Design and methods. Newbury Park,
CA: Sage.
[Author Affiliation]
Daniel DAVID*
* Corresponding author:
Email: danieldavid@psychology.ro
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RATIONAL-EMOTIVE BEHAVIORAL
INTERVENTIONS FOR CHILDREN WITH ANXIETY
PROBLEMS
From:
Journal of Cognitive and Behavioral Psychotherapies
Date:
March 1, 2008
Author:
Wilde, Jerry
More results for:
APPLICATION OF REBT AND SELF ESTEEM publication:["Cognitie Creier
Comportament"]
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1454505541.html
Abstract
One of the most efficient anxiety management techniques involves the use
of distraction in which clients are encouraged to substitute a calming mental
image to interrupt the anxiety producing thoughts. This article also provides a
detailed explanation of rational-emotive imagery (REI), which is a technique
that employs relaxation prior to clients generating their own rational coping
statements. Finally, a progressive thought-stopping technique is examined. In
this intervention, the therapist provides successively less direction and
guidance in the hopes that clients will be able to master this technique for
use independently.
Anxiety disorders are among the most common mental and emotional
problems to occur during childhood and adolescence. According to the U.S.
Department of Health and Human Services (1999), 13% of children and
adolescents ages 9 to 17 experience some type of anxiety disorder. In
community samples of adult populations, the range of anxiety disorders was
between 5 - 20% with a majority of the estimates lying above 10% (Costello
& Angold, 1995). Blanchard, et al., (2006) found that 36% of parents report
concerns about the possibility of their children struggling with anxiety.
If left untreated, anxiety disorders can persist into adulthood (Keller, et al.,
1992, Pfeffer et al., 1988; Spence, 1988) which may in part explain why the
lifetime prevalence rate for anxiety disorders is 28.8%, with a 12-month
prevalence of 18.8% (Kessler, R. & Merikangas, K., 2004). The same study
reported the most common subtypes of anxiety disorders to be specific
phobia (12.5%), social anxiety disorder (12.1%), and post-traumatic stress
disorder (6.8%).
The cardinal tenet of REBT is that emotions are not caused directly by
events but are primarily the result of the thoughts and beliefs an individual
has about the event. Therefore, if children are able to modify their thoughts
about an event, they will change their feelings as well. One of the simplest
and most effective techniques designed to bring about a change in thinking
involves the use of a distraction technique (Wilde, 1997b; Wilde 1996b; Wilde
1995).
Distraction is not an "elegant solution" as Ellis would say. It does not involve a
change in assessment of the event and, therefore, it would not be considered
to be bringing about cognitive restructuring. Distraction, as the name implies,
merely attempts to help children think of something other than their current
situation. This is more difficult than it sounds because when children are
getting anxious, the only thing they seem to be able to think about is the
situation at hand. That is why clients need to decide what to think about
before they start becoming anxious.
Encourage clients to pick "a scene" to use before they encounter the event
they become anxious about. This memory should be either the happiest,
funniest, or most relaxing scene they can remember. For example:
Have clients take a few minutes and think about the distraction scene. You
may need to help clients select the scene that fits their individual needs. Now
they need to practice imagining this scene several times daily for the next
few days or weeks. When clients have some free time have them close their
eyes and picture their distraction scene. Clients should be advised to bring in
all the details that they can possibly remember to make the scene vivid.
The idea is to switch to this distraction scene when the clients find
themselves getting anxious. Instead of focusing on the situation they are
getting anxious about, they are to concentrate on their distraction scene.
Instead of getting anxious before an important examination in school, they
are to concentrate on the distraction scene until the feelings start to subside.
Whenever they feel themselves getting anxious, they are to switch to their
scene.
It is impossible for clients to think of a distraction scene and still become
anxious. Since anxiety is produced by beliefs, thinking about a funny or
happy memory will keep them from getting upset or minimize the intensity of
the emotions.
Start by having the child vividly describe the troublesome scenario. Get as
many details as possible about the sights, sounds, and events in this
situation. Then have the child get as relaxed as possible in his or her chair
with both feet on the floor. Spend several minutes describing relaxing images
until you can see the behavioral manifestations of relaxations starting to
appear. The use progressive relaxation techniques with the successive
contracting and relaxing of various muscle groups can be very helpful. After
the client appears to be sufficiently relaxed, start with the following dialogue.
Therapist: Anna, I want you to listen very closely to what I'm going to tell you.
I want you to be aware only of my voice and focus on what I say. Try to block
everything else out of your mind for the time being.
Imagine you are back in your classroom and students are taking turns
reading aloud. Picture the room in your mind. See all the posters on the walls
and everything else that is in your class. Now go ahead and let yourself feel
like you do when it's reading time. Feel all the anxiety you felt back then.
Stay with that scene and try to feel just like you felt in the class. When you
feel that way, wiggle your finger and let me know you're there.
(Author's note - It's a good idea to look for behavioral signs confirming that
the child is actually feeling anxious. The jaw may tighten, eyebrows furrow
and many children will shift or squirm in their seats.)
Stay with that feeling. Keep imagining that you are in your classroom.
(Author's note - Allow the child to stay in this state for approximately 20 to 40
seconds. Remind him or her to mentally stay in the situation.)
Now I want you to keep thinking you are in the class but I want you to calm
yourself down. Stay in the classroom in your mind but try to calm down.
Instead of being very upset, try to get calmer. Instead of being really
anxious, try to work toward feeling calmer. Keep working at it until you can
calm yourself down. When you can make yourself calm, wiggle your finger
again.
Usually students can reach a state of relative calm within a fairly short period
of time. Once a child has wiggled his or her finger, it is time to bring him or
her back to the here and now. Simply say something like, "Okay, now open
your eyes." Next ask, "What did you say to yourself to calm yourself down?" If
the child was able to calm down, he or she had to be thinking some type of
rational coping statement. The only other way to calm down would be to
mentally leave the situation (i.e., no longer visualize the classroom). This
usually doesn't happen but if it does, try the exercise over encouraging the
child to keep imagining the scene but working to calm down.
After completing the imagination game students should then be able to state
the thought that allowed them to calm down. A typical calming thought that
might have been produced from the above scenario would be, "Even though I
don't read well, it's not that big of a deal. It doesn't mean I'm a bad person.
Other students have problems reading aloud."
Once the child has produced a rational coping statement, write it down. Now
he or she can practice this mental imagery several times a day and use this
same calming thought each time. In effect, this technique allows kids to
mentally practice dealing with a difficult situation in a new, more productive
way. It's very important that they practice REI on a regular basis if they are
going to learn to handle their anxiety in a more productive fashion.
THOUGHT STOPPING
It essential that the therapist spend time helping clients learn to distinguish
between rational and irrational thoughts. It is beyond the scope of this article
to delve too deeply into that issue. Interested readers can refer to Wilde
(1997a) for detailed information on teaching rational thinking skills to
elementary students.
The problem with most thought stopping interventions is that they stop at
this point. Clients can learn how to stop a disturbing thought but unless they
can replace the anxiety-producing thought with a rational cognition, the
original thought will quickly return. The next important step involves having
clients think about positive, rational and/or calming thoughts that could
substitute for the anxiety producing thought. Clients are taught to imagine
the anxiety-provoking situation and when they began to think irrational
thought they are to say their rational coping statement aloud. Once again,
practice this until clients report that they are able to consistently reduce their
anxiety to a manageable level. The use of a self-report scale (such as the
subjective units of discomfort scale) with a range from 1-10 can be helpful to
quantify the intensity of their emotions. The final step involves having clients
practice transferring the rational coping statement from an overt statement
to internal dialogue. Now they are to merely think their rational coping
statement whenever they notice they are beginning to feel anxious.
SUMMARY
Anxiety problems are among the most commonly diagnosed mental and
emotional problems to occur during childhood and adolescence. Research
suggests that if left untreated, many children will struggle with anxiety later
in life. The interventions discussed in this article are brief and not difficult for
children to learn. To maximize the potential for success, children need to be
closely monitored and given encouragement. Be prepared for both success
and setbacks during the course of treatment. Learning anxiety management
skills will take time and effort but the benefits are well worth the effort.
[Reference]
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Pfeffer, C., Lipkins, R., Plutchik, R. & Mizruchi, M. (1988). Normal children at
risk for suicidal behavior: A two-year follow-up study. Journal of the American
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Wilde, J. (1994). The effects of the let's get rational board game on rational
thinking, depression, and self-acceptance in adolescents. The Journal of
Rational-Emotive and Cognitive-Behavior Therapy, 12, 189-196.
Wilde, J. (1997b) Hot stuff to help kids chill out: The anger management book.
East Troy: WI: LGR Publishing.
[Author Affiliation]
Jerry WILDE *
Copyright A.S.C.R. PRESS Mar 2008. Provided by ProQuest LLC. For permission to reuse this article, contact
Copyright Clearance Center.
CASE STUDY METHODOLOGY: FUNDAMENTALS
AND CRITICAL ANALYSIS
From:
Cognitie, Creier, Comportament
Date:
June 1, 2007
Author:
David, Daniel
More results for:
APPLICATION OF REBT AND SELF ESTEEM publication:["Cognitie Creier
Comportament"]
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ABSTRACT
I. INTRODUCTION
1. A Brief History
The case study research method is defined as "an empirical inquiry that
investigates a contemporary phenomenon within its real-life context, when
the boundaries between phenomenon and context are not clearly evident,
and in which multiple sources of evidence are used" (Yin, 1984, p. 23). Thus,
case study methodology uses in-depth examination of single and/or multiple
case studies, which provides a systematic way of approaching the problem,
collecting and analyzing the data, and reporting the results.
(2) Case study methodology can be used to test a scientific theory. This is a
heated discussion in epistemology. As we have shown above, many critics of
the case study methodology think that the study of a small number of cases
cannot offer a basis for the reliability and generality of findings and thus, in
testing a theory.
(3) When no other cases are available (i.e., critical and/or unusual cases), the
researcher is limited to case study methodology (i.e., single-case design). If
the objective is similar to that described at point 4, case study should be the
choice research methodology.
Case study is not useful in testing a theory based on verification, and then
arguing that the theory is validated. Generally, the choice for or against case
study methodology depends on the problem we have to solve. If the problem
implies knowledge based on sampling logics, case study methodology should
be avoided.
a. The research should start with the problem - the study question. The
problem can be defined as a discrepancy between an initial state (what he
have) and a final state (what we want to have). A rigorous problem will define
precisely the initial state and will specify clearly the objectives. A serious
problem is one in which the discrepancy between the initial and final states is
approachable by current methodology. For example, if my proposed final
state is to eliminate all mental disorders in the next two years, this will not be
considered a serious problem considering current knowledge in clinical
psychology and medicine.
b. The objectives and/or the hypotheses should be made clear (if they exist).
c. The next step involves defining the unit of analysis and than data
collection. It must be made clear that data collection can be guided by either
quantitative and/or qualitative methods. Data can come for various sources
and depending on the problem and objectives, it can be collected
qualitatively (e.g., by interview) and/or quantitatively (e.g., numerically).
e. In the next step, logic is used to link our results to our objectives and/or
hypotheses. This is where people who use case study methodology make
most mistakes (e.g., generalize when it is not the case). Therefore, it is
fundamental to binocularly integrate the logics and the design of the study to
avoid such errors.
II. APPLICATIONS
Case Study in Research (adapted after David & McMahon: "Clinical strategies
in cognitive behavioral therapy; a case analysis" published in the Romanian
Journal of Cognitive and Behavioral Psychotherapies, vol. 1, no. 1, September
2001, pp. 71-86; see also David, 2003; David et al., 2004; David, 2006a;
2006b). The case of "Dana" is a classic one in the Romanian clinical
literature; this is why it is presented based on its previous publications,
although the context is new (i.e., case study methodology).
1. The Problem
1.1. Introduction
Many people find the distinction among "Behavior Therapy (BT)", "Cognitive
Therapy (CT)", "Cognitive Behavior Modification (CBM)", and "Rational
Emotive Behavior Therapy (REBT)" confused and confusing (Dobson, 2001;
Lazarus, personal communication). We believe that the time has come to stop
elaborating on details regarding the various schools and systems of cognitive
behavior therapy/therapies (CBT), and (1) to focus on the science and theory
of cognitive behavior therapy; (2) to discuss treatments of choice for specific
conditions; (3) to focus on what is and what is not empirically supported; and
(4) to develop really good manuals so that experimentally oriented clinicians
can endeavor to test, repudiate or replicate particular claims and findings. We
think that all these goals can be accomplished under the umbrella of
cognitive science. Cognitive science attempts to understand the basic
mechanisms governing human mind, basic mechanisms that are important in
understanding behavior studies by other clinical and social sciences.
Cognitive science studies the foundation on which many other social and
clinical/psychological sciences stand (Anderson, 1990).
1.2. Cognitive science and emotional problems; A brief presentation (see also
David, 2003; David et al., 2004)
Following the previous distinction between hot and cold cognitions, according
to the appraisal theory of emotions, emotional problems will only appear in
cases 1 (distorted representation/negatively appraised) and 2 (non-distorted
representation / negatively appraised). In case 1 (distorted representation /
negatively appraised), if one changes the distorted representations (e.g., "He
hates me") into an accurate one (e.g., "He does not hate me"), one may end
up changing the negative emotion (anxiety) into a positive one (happiness).
However, the individual may still be prone to emotional problems because
the tendency to make negative appraisals (e.g., "It is awful that he hates
me") is still present. If one changes the negative appraisal (e.g., "It is awful
that he hates me") into a less personally relevant one (e.g., "It is bad that he
hates me but I can stand it"), it is probable to change the dysfunctional
emotion (anxiety) into a functional but still negative one (concern; for the
distinction between functional and dysfunctional emotions see Ellis, 1994). A
strategy that will change both distorted representation and negative
appraisal seems to be a better choice. In case 2 (non-distorted
representation/negatively appraised), the choice seems to be the change of
negative appraisal that would generate a positive (happiness) or negative
(concern) functional emotion. Another possibility is to change a non-distorted
representation (e.g., "He really hates me") into a positively distorted one (i.e.,
positive illusion: "His negative comments are a way of communicating that
he considers me a strong and reasonable person"). However, as in the first
case, in the second situation we may change both representation and
negative appraisal.
Dana is a 28 years-old physician, mother of one, who lives with her husband,
and who has been working full-time as a fellow in gastro-enterology for the
past 3 years.
Chief Complaint. Dana sought psychological treatment for panic attacks and
generalized anxiety at the end of and the beginning of 2000 (18 sessions).
Two months before treatment she had had three panic attacks and feared
having another one. She also reported: "Since about 1991, I have been
feeling nervous and excessively anxious about my life (e.g., "my future job as
a physician"), my relationships (e.g., "with colleagues and my husband") and
my significant activities (e.g., "my school performance, my doctorate"), but
right now I am much more concerned about the recent panic attacks".
History of Present Illness. In 1991, Dana moved away from home, far from
her overprotective parents, to study medicine at a prestigious university.
Starting then she began feeling helpless and she reported attacks of
excessive anxiety and "worry about everything" (emotional symptoms).
These emotional states were often associated with muscular tension, feelings
of weakness, fatigue, and sleep disturbance (physiological symptoms). She
always found it difficult to control these physical symptoms and,
consequently, she started avoiding activities that required physical effort
(behavior symptoms). She thought that her symptoms would affect her
performance at work and her value as a competent human being (cognitive
symptoms); consequently, she often felt helpless, with low self-esteem. Her
GP and then a psychiatrist prescribed her Buspar (Buspirona) (in 1993). After
several months of medical treatment, she gave it up, as it had reduced
symptoms less than she expected. The first panic attack occurred while she
was preparing for her doctoral exam about two months before our first
meeting (1999). About one month later she had another attack. At the time
of the second attack she was at home cleaning her apartment. The third
panic attack occurred just one week before our first meeting, while she was
home alone, preparing a paper for a scientific congress. Her panic symptoms
included the following: Emotional symptoms: intense fear of loosing control,
helplessness and discomfort; Cognitive symptoms: believing that she was
going to die, had heart problems, and that she was going to faint and
collapse; Behavioral symptoms: avoiding physical effort and looking for safe
places in case she fainted; Physiological symptoms: palpitations, trembling,
and chest pains. She consulted a psychiatrist regarding these symptoms, and
was prescribed XANAX just two months before our first meeting.
The major stressors in Dana's life were mainly social. She was an
overprotected child, and being far from home and from the protection of her
parents during training in medical school was the first major stressor that
might have precipitated her generalized anxiety (1991). Moreover, before
getting married (she got married in1998), Dana had hoped that her husband
would be a real support for her. She believed that he could help her to
overcome her anxiety and her "worries about everything". Unfortunately, her
husband's job was highly demanding. He was an assistant professor and a
researcher often working hard late at nights and on weekends. He was not
very involved in the household and in their child's education (the birth of
Dana's son was another stressor and opportunity for her to worry about:
"Considering that I am so busy, how will I have enough time for my son?").
Consequently, she felt overwhelmed by her life as wife, mother, physician,
and student, doing her full-time job as physician, cleaning the apartment,
cooking, taking care of her son, and preparing for her exams doctoral exams.
These were the conditions in which her first panic attacks developed (1999).
Personal and Social History. Dana was an only child. She described her father
as very rigid, controlling and concerned with the future of his daughter.
Because of his authoritative attitude she had been afraid to argue with him
or ask something from him (the same thing is true even now as an adult). She
described her mother as a warm person, highly concerned with the education
and the future of her daughter. Dana remembered that during kindergarten,
primary and secondary school she had been overprotected by her parents but
that she had not liked that attitude at all. For example, every morning they
left her at school and in the afternoon they picked her up. Because of this,
she had no opportunity to have friends and/or be with her colleagues. She
described herself as a girl (and now a woman) with very poor social and
assertiveness skills both at home and in other social situations. During high
school she started preparation for medical school. Both parents wanted her to
attend medical school. They allowed her to have a boyfriend (the relationship
was not very intense); however, they were only allowed to meet at her home
or go out for several hours in the afternoon. After starting medical school
(1991), Dana had to move to another town. During the first year (she was 18)
her parents visited regularly. They did not want her to live in a dorm with her
colleagues, so they rented an apartment where she could learn without being
disturbed by others. During her first year in medical school she started
experiencing intense signs of generalized anxiety and some symptoms of
subclinical depression. She felt alone, helpless, and started to worry about
everything (but not about the separation from her parents - this was one of
the reasons why we did not consider a diagnosis of separation anxiety!).
During her second year of study (1993) she decided to see a general
practitioner and a psychiatrist who prescribed her Buspar (Buspirona). After
several months she gave up treatment because the symptoms of generalized
anxiety persisted. Despite these symptoms she graduated medical school
successfully in 1997 and started working as a fellow in gastro-enterology. She
met her husband around the same. She described him as very bright, strong
and mature man, 15 years older than she was. They fell in love and got
married in 1998. They live in the same town where she graduated medical
school. After one year of marriage their son was born. In 1998 she started a
doctoral program in medicine. During their second year of marriage (1999)
she experienced her first panic attack. I (DD) met her in 1999 after she had
experienced three panic attacks. Beside psychotherapy, Dana took
medication (XANAX) prescribed by her psychiatrist.
Medical history. Dana had no medical problems which could influenced her
psychological functioning or the treatment process.
Mental Status Check. The patient was fully oriented with an anxious mood.
D. Strengths and assets. Dana is a bright person with a good physical health.
She loves medicine and she is very disciplined. She wants the best for her
and her family and consequently, no effort is to high to attain these goals.
She has lived with generalized anxiety for almost 7 years. The coping
mechanisms she employed during these years were: avoiding problems,
avoiding physical exercise and studying hard.
2.3. Treatment plan; A cognitive therapy perspective (by Dr. Daniel David)
A. Problems list: (1) Dana's panic attacks; (2) general feeling of worry about
everything (generalized anxiety and subclinical depression); (3) relationship
with her husband concerning the support he might offer to her (4) low
selfesteem and social and assertiveness skills.
B. Treatment goals: (1) to reduce panic attacks (including panic about panic);
(2) to reduce negative distorted thinking with impact on generalized anxiety
and subclinical depression; (3) to build assertiveness and problem solving
skills in order to improve the relationship with her husband and her ability of
solving practical problem; (4) increase social skills with impact on her
dependent personality traits.
C. Treatment plan. The treatment plan was to first reduce Dana's panic
attacks (including panic about panic) and then her generalized anxiety and
subclinical depression. We also planned to work on her assertiveness, self-
esteem, and social skills. Finally, some practical problems were approached
and a relapse prevention program was introduced.
1. The patient was taught a distraction technique for panic attacks (e.g., to
describe in detail all the objects in the room). This technique: (a) would
counter Dana's belief that she had no control over her anxiety; (b) be a useful
symptom management technique when it was difficult to challenge automatic
thoughts; and (c) be a potent demonstration of the cognitive model of
anxiety to which Dana was initially quite reluctant. She was then introduced
to voluntary hyperventilation technique. This was useful in modifying her
catastrophic interpretations of the bodily sensations she experienced during
panic attack. Controlled breathing was also introduced with the purpose of
reducing hyperventilation.
2. The patient was taught standard cognitive restructuring and behavioral
techniques for her automatic thoughts, catastrophic interpretations, and later
for her core beliefs. We also focused on changing hot cognitions by working
at different levels of abstraction. These techniques allowed Dana to
understand maladaptive thoughts and assumptions and thus significantly
reduced anxious and panic symptoms, subclinical depression, and some of
the dependent traits.
Outcome. Dana's therapy extended over 18 sessions. Six months after the
end of therapy, Dana had no recurrence of panic attacks or symptoms of
subclinical depression. However, some symptoms of generalized anxiety
persisted but they did not meet the DSM IV criteria for generalized anxiety
disorder. Dana's assertiveness and social skills improved significantly and had
a positive impact on her relationships (including with husband and parents)
and on the reduction of dependent personality characteristics. All these
results are operationalized in a single case experiment design: multiple
baselines across symptoms.
2.5. The treatment plan; An REBT strategy (by Dr. James McMahon).
An REBT treatment regimen was put into place, the process of intervention
was commented upon and acceptable to both patient and therapist. Several
issues were emphasized to her namely, that the idea was to be better not get
better, that two primary aspects on the neurotic continuum of thinking-
feeling were her tendency to exaggerate (awfulizing) and to avoid negative
emotions, thereby giving her temporary comfort but long-term misery (low
frustration tolerance). Also it was discussed with Dana how her problems
seemed to be related to demandigness oriented to her own person (e.g., "I
have to do everything at high standards") and others (e.g., "Others have to
help me"). If these demands are not attained, then she moves into self-
downing (e.g., I am weak), awfulizing (e.g., "It is awful") and low frustration
tolerance (e.g., "I cannot stand it"). Session 2-4 went to the heart of panic.
Checked was the secondary problem (panic about panic) and the irrational
beliefs involved (e.g., "I have to be in control otherwise it is awful and I
cannot stand it"; DEM, AWF and LFT). The primary emotional problem was
then focused upon (where we identified others DEM, AWF, LFT and SD).
Session 5-7 stressed self-worth issues related to generalized anxiety and
subclinical depression (e.g., stubborn refusal to judge herself, examining her
roles and how to judge them through the who/what process, rational-emotive
imagery in which she perceived herself to be in control of her own life and
that she was in charge, and disputation of other irrational beliefs). Sessions
8-12 involved further restructuring of IBs into adaptive alternatives (at
different levels of abstraction) and how to distinguish beliefs from feelings
about beliefs. She kept a log of the type of empirical, logical and pragmatic
disputations. Session 13-18 involved dealing with issues of dependency
throughout her life, looking for alternative conceptions. Some practical
problems were approached, and revisiting panic and anxiety situations was
undertaken to preclude regression.
Outcomes. Dana reported in the last session that she was free of panic
attacks, that she could distinguish rational from irrational beliefs, and that
she generally felt happy and liked herself. Regarding her own goals, she
indicated that she was generally happy but busy with her family and work,
that she judged that she could head off panic attacks in the future, and that
she was assertively negotiating home duties with her husband. The patient
and the therapist judged that she achieved good results therapeutically and
as a person.
2.6. Discussion
2.6.1. Comment upon the cognitive therapy strategy (by Dr. James
McMahon).
The work of Dr. Daniel David was generally masterful: good diagnosis, good
interventions, and the goals were attained. He used all available CBT
techniques that were appropriate by distinguishing automatic thoughts vs.
core beliefs vs. evaluative cognitions. However, I would mention that the
distinction between core beliefs (cold cognitions) and evaluative cognitions
(hot cognitions) is not always clear in cognitive therapy, although here, Dr.
David made it very clear. Also, many cognitive therapists prefer to work only
at the level of distorted cold cognitions, both surface and deep, rather than
at both cold cognitions and evaluative beliefs. In that case, the patients may
feel better but not get better. For example, they may feel better because the
activating events (e.g., "It is not true that she laughs at me") are not
dangerous, but the individual still may be prone to emotional problems
because the tendency to make negative appraisals (e.g., "It is awful when she
laughs at me") of activating events incongruent with their goals (e.g., "She
really laugh at me") is still present. However, here, Dr. David approached
correctly both types of cognitions. If there were one negative aspect, that
would be that therapy did not get to the person. Rather, therapy dealt with
symptoms, and then their causes and cure. While achieving personhood in CT
can be inferred, it can only be inferred as one of the several schemas since
the theory purports to be empirical and so deals with piece-by-piece
examples of pathology. Contradistinction, REBT theory clearly tries to
achieve fundamental philosophical change and so is person driven.
I think that Dr. McMahon's elegant REBT is really elegant: great clinical
approach! Unlike me, Dr. McMahon attacked evaluative cognitions directly. I
myself would approach evaluative cognitions, but after a careful challenging
of automatic thoughts and core beliefs. My general criticism to Dr. McMahon's
approach would be that by directly changing evaluative cognitions and
assuming that distortions are real (e.g., "Let us suppose that you are indeed
not able to work at high standards; How does this make you weak and
inadequate as a person?" or "How is this awful?", etc.) one may change a
dysfunctional emotion (anxiety) into a negative functional emotion (concern)
because automatic thoughts (e.g., "I will not be able to prepare my
presentation") and deep cold cognitions are not directly disputed in the
elegant REBT. I know that Dr. McMahon might suggest that by changing
evaluations one indirectly changes distortions too, and indeed, one may
invoke some corpus of research which supports this hypothesis (Dryden,
Ferguson, & Clark, 1989 but see Bond & Dryden, 2001). However, sometimes
distortions may gain functional autonomy from the evaluative cognitions (see
Allport's concept of "functional autonomy"); in this case the change of
evaluative cognitions might not be accompanied by a change in the
distortions. Consequently, the client may feel better (e.g., "concern" rather
than "anxious") but not achieve the best results (e.g., "relaxed", "calm" or
even "happy"). On the other hand, as Ellis repeatedly mentions, (Ellis, 1994),
not all patients may benefit directly from elegant REBT. However, in our case
the patient seems to be in a positive emotional state and thus, Dr. McMahon's
direct disputation of IBs also seemed to change cognitive distortions (i.e.,
elegant REBT). If that had not happen, I suppose that Dr. McMahon would
have forcefully disputed the distortions too (i.e., inelegant REBT). The
difference between our approaches seems to be in terms of strategy. I
started with automatic thought, core beliefs and then evaluative cognitions.
With bright clients, Dr. McMahon seems to prefer starting with evaluative
cognitions and then maybe working on distortions, if necessary (I know that if
the change of irrational beliefs was not accompanied by a change in
distorted cold cognitions, Dr. McMahon would directly examine automatic
thoughts and other distortions - personal communication). I would like to see
some research evaluating concurrently these two different cognitive
strategies. I assume that their efficacy may differ depending on the clinical
condition (e.g., the type of psychopathology, the type of client).
III. DISCUSSIONS
After a short history, this paper briefly and critically presented the
fundamentals of case study methodology. We have then exemplified, by
using the case of "Dana" from our previous publications, how it can be
employed in clinical practice. We hope that the message to take home after
reading this article is clear. Case study methodology is not rigorous or less
rigorous per se. It becomes rigorous or less rigorous depending on the type of
knowledge we want to generate in order to solve specific problems. This is
true for all the research methods. The problems which case study is best fit to
solve are those related to exploratory studies (i.e., generating new theories),
to critical, and unusual cases. It is less fit to test a theory although, if
conditions for falsifiability are met, it can be implemented with this purpose
as well. When used appropriately, case study methodology is very rigorous,
comparable with any other research method. By appropriate we mean two
things: (1) adequate to the problem it is intended to solve; and (2)
implemented at high standards in terms of internal constraints and steps that
need to be followed.
[Reference]
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rationalemotive hypothesis: I. Performance in an academic seminar. Journal
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Ingram, R. E., & Siegle, G. J. (2001). Cognition and Clinical Science: From
revolution to evolution. In K. S. Dobson (Ed.), Handbook of cognitive-
behavioral therapies. New York: Guilford Press.
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[Author Affiliation]
Daniel DAVID*
* Corresponding author:
Email: danieldavid@psychology.ro
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ABSTRACT
THEORETICAL BACKGROUND
Moreover, studies show that approximately 70% of the young people who
benefit from mental health services do so only at school, which turns the
educational system into a privileged system for offering these types of
services for young people (Farmer, Burns, Philips, Angold, & Costello, 2003;
Gonzales et al., 2004). But as the number of young people that could benefit
from such services increases, so does the need of implementing empirically
sustained interventions in schools (evidence-based interventions) (Gonzales
et al., 2004; Stoiber & Kratochwill, 2000). REBE is one such intervention, as
we see later on.
Miller (1978) compared REE with a condition combining REE with behavioral
reinforcers, another one combining REE and homework, and a control
condition. The subjects were 96 children, with low and high IQ levels. The
dependent variables were the children's knowledge, neuroticism and trait-
anxiety. The results of the three experimental groups were significantly
superior in comparison to the control group. Intelligence did not prove to
have an effect on the results (see also Silverman, McCarthy, & McGovern,
1992).
Cardenal Hernaez and Diaz Morales (2000) studied the effect of three months
of REE versus relaxation techniques on self-esteem and anxiety level, in 12-
14 years old children from Spain. 93 students were randomized in the 2
experimental groups and the control group. The measures applied consisted
of the Piers-Harris self-concept scale, a body attraction scale and STAI.
Measures were carried out for pretest, posttest and at three months follow-
up. Results showed that both experimental conditions equally contributed to
the global increase in selfesteem and the reduction of anxiety.
One of the most recent meta-analysis (Gonzales & al., 2004) regarding the
efficiency of rational-emotive behavioral therapy (REBT) in a wider range of
emotional and behavioral problems (including anxiety) highlights some
important discoveries. It was carried out on 19 peer-reviewed studies and it
analyzed 5 domains of results (disruptive behavior, impropriation of
rationality, GPA -grade point average, self-concept and anxiety). Their first
and more general conclusion is that, subsequent to a REBT intervention, the
modal child or adolescent had better performances, regardless the type of
result considered, than approximately 69% of the control, no treatment
groups. But another conclusion proves very interesting and can also act as a
justification for the current study: REBT intervention seems to be efficient
both for children and adolescents with an identified clinical problem, as well
as for those without one. This motivates preventive interventions, targeting
sub-clinical problems or problems that have not yet manifested, but for which
we know the child to be vulnerable. Another important conclusion of this
meta-analysis, which contributes even more to justifying the current study,
states that the efficiency of a REBT intervention is much higher, IF it
addresses younger children (primary school) than older ones (secondary
school or high-school). Another conclusion warns about the danger of the
intervention not being effective because of its too short duration: REBT
efficiency is higher in conditions with a medium (675-770 minutes) or high
(1200-2115 minutes) duration of the intervention. Regarding anxiety, effect
sizes for these measures are presented in 6 of the 19 studies (12 effect
sizes), leading to a .48 effect size.
Bernard, Ellis and Terjesen (2006) express a similar opinion, drawing the
attention to the close relations that exist between children's emotional and
behavioral problems and certain developmental problems in the domain of
cognitive processing of emotional or social aspects. It becomes obvious that
any therapeutic approach of children, be it preventive or corrective, has to
take into account the fact that they are developmentally vulnerable to some
cognitive processing errors (Bernard, et al., 2006). Many of these errors are
due to the ontogenetic features of the cognitive development of 9-10 years
old children.
1. Children who benefit from the REBE intervention will present a more
significant reduction of irrationality than those who benefit from the sham or
no intervention.
2. Children who benefit from the REBE intervention will present a more
significant reduction of anxiety (global score as well as specific problem
categories) than those who benefit from the sham or no intervention.
METHOD
Subjects: Subjects were 63 children, aged between 9 and 10 years from three
3rd grade classes, selected from 2 schools in Cluj-Napoca. 36% of all children
were girls and 64 % boys. Participation in the program was voluntary and
school, teachers' and parents' agreement for the program were previously
secured. We could not in this case ensure a random selection and distribution
in groups. Even if the schools were randomly selected, in order to carry out
the intervention we depended on the availability of the school-principle,
teachers and parents. Moreover, we were interested in seeing how the
intervention works in an ecological environment, because that will be the
setting for structured mental health programs dealing with children's
emotional difficulties. To prevent some of the problems that arise from the
lack of randomized selection, we controlled for the existence of significant
differences between the 2 groups on measures of anxiety and irrational
beliefs.
Procedure: The testing phase was individual for all subjects. The same
instruments were used in the pre- and posttest phase (after the intervention).
The intervention phase lasted for 3-4 months, with 2 regular sessions of
about 45 minutes per week (20 sessions of actual intervention for the REBE
group and the sham group).
2. Beliefs and behaviors (understanding what beliefs are and how they
determine our emotions and behavior - the ABC model)
Instruments:
* The Spence Children' Anxiety Scale - SCAS (Spence, 1994). The scale is
composed of 38 items, 6 filler items and an open question. The child is asked
to read each statement and appreciate how often that particular thing
happens to him on a 4-point scale. The questionnaire offers a global anxiety
score, as well as scores for specific clusters of anxiety related problems.
These clusters are represented by the subscales of the SCAS: panic attack
and agoraphobia, separation anxiety, physical injuries fear, obsessive-
compulsive behavior, generalized anxiety. It is constructed following the DSM-
IV criteria, which enhances its precision in accurately identifying anxiety
problems and it is meant to be an indicator of the number and severity of
anxiety symptoms. The authors also establish cut-off points, circumscribing
three problematic categories in which the subject could be placed: at risk
(16% of the population), borderline clinical (7%), clinical (2-3%). The SCAS is
in the final stage of its adaptation for the Romanian population (Benga, 2006,
in progress), and the preliminary date indicate good reliability, both for the
global scale and for its subscales. Data from other populations (German,
Dutch) indicated very good reliability for the scale and its subscales and good
discriminate validity, using a clinical anxiety diagnosis as criterion (Spence,
1998).
* The Spence Children' Anxiety Scale (SCAS) - Parent version (Spence, 1994).
The content, cotation and interpretation are almost identical to the SCAS. It
consists of 38 items and an open question. There are fewer studies regarding
it, but the data indicate satisfactory to very good reliability for the scale and
its subscales and good discriminant validity regarding the clinical anxiety
diagnosis (except for the generalized anxiety subscale)- Nauta et al., 2004. It
is also being adapted on the Romanian population (Benga, 2006, in progress).
* The Child and Adolescent Scale of Irrationality - CASI (Bernard & Laws,
1999): It is addressed to children and adolescents between 9-18 years of age
and is comprised of 28 items, formulated as statements about which the
subjects to express their agreement on a 5-point Likert scale (1- strongly
disagree, 5- strongly agree). CASI overcomes the problems presented by the
other existent irrational beliefs scales, as the theoretic model it was based on
takes into account the recent theoretical and empirical discoveries in REBT
and REBE research, and the items are exclusively cognitive ones. The scale
was adapted on Romanian population (Popa, 2006). The validation study used
factorial analysis and 4 factors were identified (consistent with the ones in
the initial validation study). These are: low tolerance to frustration brought on
by rules, global evaluation of the self, demands for fairness, low tolerance to
frustration brought on by work (Popa, 2006). The scale has good global
fidelity (α Cronbach= 0.84) and its subscales have satisfactory to good
fidelity (Popa, 2006).
RESULTS
Descriptive data
In the table above, we display the means and standard deviations for the
anxiety measures (pre and post-test).
Intra-group comparisons
We used the t test for paired samples. Significant values are marked with an
asterisk (p<.01). We chose an alpha threshold of .01 (even though the
commonly accepted value for alpha in psychology research is .05), because
in this case we wanted to keep the type I error as small as possible. An
educational intervention as the one employed here requires a significant
quantity of resources (time, materials, human resources) and we have to be
sure about its efficiency before engaging all these resources to implement it.
Therefore, we have to be more strict in assessing its efficiency and should
recommend its implementation only on the basis of a clearly distinguishable
effect. So we chose a lower alpha threshold than it is usually accepted in
order to prevent false positives (finding a significant effect when in fact there
is none) as much as possible.
We can see that the effect of the intervention in each group concerning
irrational beliefs is practically insignificant. Regarding the anxiety level, we
must first notice that the REBE group displays significant improvements on
the panic attack and agoraphobia subscale, improvements that are not
present in the other groups. An interesting result is that both the REBE group
and the sham group show significant improvements on the measures of
generalized anxiety. Also both the REBE group and the control group show
significant improvements on the obsessive compulsive disorder subscale.
However the most important result for the present study involves the level of
specific REBE knowledge, which has significantly improved only in the REBE
group.
Inter-groups comparisons
We must note that in the pretest phase the differences among the 3 groups
are not significant at p<.01 for irrationality (F=2.66) and anxiety (F=4.93)
both as global scores and subscale scores. However, we must acknowledge
that the means of the REBE group (for anxiety) are consistently higher
(although not significantly so) than those in the other groups, which was also
an ethical consideration that oriented us to using that particular group as the
target group. At posttest, there are still no significant differences at p<.01
among the 3 groups for anxiety (F=3.67) or irrationality (value for F=0.53).
For a more precise assessment of the potential change we also compared
effect sizes (the magnitude of change) for each group. In this case we again
had no significant differences among the groups at p<.01 on measures of
anxiety (F=0.51) or irrationality (F=2.54). All the above, correlated with the
intra-group comparison data, allow us to conclude that in the particular case
of these classes of students, the REBE intervention did not have a significant,
consistent, transparent effect on irrationality and anxiety. However, when we
look at the data regarding the REBE knowledge, we notice that at posttest
they are significantly different in the REBE group from the sham group
(F=3.70, p<.01) and the no intervention group (F=5.26, p<.01). Moreover,
the REBE group has significantly better knowledge than the other 2 when we
look at the magnitude of change (F=5.78, for comparison to the sham group
and respectively F=5.81 to the control group, p<.01).
DISCUSSIONS
Intra-group comparisons
Starting off from this data, we came up with 2 major interpretative ways: a
procedural perspective and a developmental perspective.
The teachers could represent another source of error, similar in its action
mechanism. They too have got more time with the children and more control
and reinforcement possibilities to make their influence more consistent than
that of the intervention. We tried to control this problem since the teacher of
the REBE group had attended REBE training. Still, she was present during all
the sessions, although we specifically requested her not to intervene. It is
however possible that her presence could have acted as an inhibitor for the
adequate involvement of children in the proposed activities (especially those
that required personal examples).
Still, procedural aspects are not by themselves enough to explain our results.
The activities used were taken from a manual and were specifically conceived
for group work. We need to consider explanations at a deeper level; therefore
it would be useful for us to look at the developmental characteristics of the
children involved in this program. So the second perspective for data
interpretation is a developmental perspective. We will start off from the
observation that in the REBE group, although there is no effect in the
direction of ameliorating anxiety and irrational beliefs, there is a significant
and consistent effect on REBE knowledge. Children seem to have acquired
the knowledge being discussed, but this doesn't seem to impact their way of
thinking and their emotional problems.
The main objective of our intervention referred to the fact that, subsequently
to the activities and discussions, children would extract ideas about certain
concepts (emotions, beliefs, behaviors) and then generalize and apply these
concepts in their daily lives. However, as we have pointed out in the
theoretical part, their cognitive development is impinged on by some typical
processing errors (Bernard, et al., 2006). It may be that, in the context of this
intervention, all these translated into a limited capacity of transferring the
acquired information in real life situations, especially when dealing with
emotionally loaded content. For example a cognitive error such as that of
selective abstraction (focusing on details and ignoring essential features of
the situation) (Bernard, et al., 2006) could lead children to see the activities
used as simple games, without extracting general principles (which was the
real purpose of the activity). Even in the cases when they did extract some
regularity, another cognitive error specific to their point of cognitive
development is the situated, localized nature of their inferences and concept
application (a concept's area of application is circumscribed to the context
it was learned in). In other words, it could be that what is learned in the
classroom is only applied in the classroom and not transferred to other life
situations (e.g. family problems, problems with peers). These issues could be
even more significant as the similarities between contexts (class situation -
other life situations) are not really transparent to children. The problem
situations that are outside the actual intervention sessions may not
automatically activate the idea of applying the learned concepts. Even
though they have the declarative knowledge, it is possible that children
cannot explore the benefits of this knowledge because of their
developmental particularities. A mental health educational program should
take these issues into account.
The results are consistent with other data obtained using the Spence scales
with other populations. Nauta et al. (2004) indicate inter-correlations in the
range of 0.41-0.66 in the group of children with diagnosed anxiety disorders
and in the range of 0.23-0.60 in the group without diagnosed anxiety
disorders (our results fit in that range). The highest degree of agreement is
met for subscales that envisage behaviors easily observable (Nauta et al.,
2004). In our case, the significant, positive correlations were medium sized
and obtained in the cases of separation anxiety and physical injuries fears,
which enclose observable behaviors.
Also we cannot omit the sociological explanation, which is the fact that
parents spend less and less time with their children and thus don't have
sufficient time to observe such problem behaviors. Actually the parents
expressed this point in the preliminary discussions (e.g. "I barely see my
child, I don't now what he does most of the time").
Based on the data obtained and the analysis carried out, possible future
research could approach:
Regarding the limitations, the first one refers to the lack of randomized
selection and distribution of subjects. We detailed this in the methodology
section, so we will not dwell on it again. Another limitation, resulting from
this, is the fact that the anxiety means of the REBE group are consistently
higher (although not significantly so) than those in the other groups. This
could also have been a factor influencing the results of the intervention. We
will also detail another important limitation which refers to the CASI and its
adaptation on the Romanian population. We chose this scale because, among
the ones that measure irrational beliefs, it is the most robust one
(theoretically and empirically). However we can't ignore the problems
presented by the Romanian version of the CASI, especially with children this
age. These could have seriously impaired the results. In brief, some of the
problems are: the use of a 5-point scale, as it is hard for children to operate
with these distinctions and they usually go for the extreme values;
negatively-worded items, that are difficult to interpret and the children have
to resort to complicated logical deductions about denying a negative
statement; the use of some terms that are hard to understand or vague, such
as "frustrated", "desperate"; the lack of age differentiated norms.
The present research raises more questions than it gives answers. But if we
were to quote Einstein "formulating a problem is often more important than
solving it". This research cannot offer clear and definitive answers on the
ecological efficiency of REBE in reducing anxiety in 9 to 10 years old children.
Yet we hope to have been able to provide some empirical data and
interpretations that can contribute to a more exact formulating of the
problem.
ACKNOWLEDGMENTS
This research was supported by CEEX-M1 Grant no. 124 (AnxNeuroCog) from
the Romanian Ministry of Education and Research.
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[Author Affiliation]
* Corresponding author:
E-mail: ioana.alina.cristea@gmail.com
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