| Suicide
is a leading cause of death among adolescents. Admittedly,
many would prefer not to talk about such a morbid
topic, yet the realities are clear if one chooses
to look at the statistics produced by the Center
for Disease and Control (CDC). Suicide rates will
continue to climb until more preventative programs
are developed. Cognitive-Behavioral Therapies (CBT)
are designed not only to reactively work with a
suicidal adolescent, but more importantly, are structured
to formulate work in a proactive manner. Nevertheless,
a review of the literature is disappointing. Moreover,
there was a paucity of research on the application
of Rational Emotive Behavior Therapy (REBT) and
its application to suicidal adolescents.
Rational Emotive Behavior Therapy (REBT) was developed
and is still practiced by Albert Ellis. It is considered
to be one the many cognitive-behavioral treatment
modalities currently used in the mental health arena.
The primary ingredients and major suppositions of
REBT are similar to Beck's and Young's ideas and
all of the other major cognitive behavioral thinkers'
models; however, there are distinct differences
within the REBT model, which deserve further exploration.
While this paper is not intended to discuss the
properties of REBT extensively, it seems necessary
to first describe some of the major tenets posited
by Ellis. First, according to Ellis and MacLaren
(1998), "rational emotive behavior therapy
is based on the assumption that cognition, emotion,
and behavior are not disparate human functions but
are, instead, intrinsically, integrated and holistic
(p. 3)." Admittedly, this basic tenet seems
in keeping with many of the other cognitive-behavioral
approaches. However, what separates REBT from the
other cognitive behavioral therapies is not the
goal of attempting to change and/or modify a patient's
cognitions, rather it revolves around REBT's philosophical
foundation. (Ellis, 1983). According to Ellis and
Bernard (1983), the difference between CBT and REBT
"is that CBT does not attempt to modify the
overall philosophy and assumptive world of clients
through the use of disputational methods (p. 9)."
Many of the CBT models seem to be more problem driven,
while REBT appears to take the position that behavior
and/or emotions are simply consequences of the patient's
core belief structure, which then leads to psychopathology
(Ellis & Bernard, 1983). After a comprehensive
review of the literature regarding REBT, I found
a paucity of research pertaining to REBT and its
application to suicide. In fact, a paucity may be
generous.
Application of REBT to the Suicidal Adolescent
According to the REBT model most commonly practiced,
there are five key components a clinician must be
familiar with (Dryden, 1995). In an effort to be
brief, the elements will be applied to a suicidal
adolescent, while at the same time attempting to
define each element. The acronym used by REBT therapists
is the "ABCDE's" of REBT. "A"
refers to the activating event. For example, an
adolescent who is contemplating suicide or is simply
thinking about suicide, the activating event could
be as innocuous as a break up with a girl or boy
friend, a poor grade on a test or simply an argument
with a friend. "B" stands for the adolescent's
rational or irrational belief about A. For example,
the adolescent may hold the cognition that because
his girlfriend dumped him, he is "no longer
loveable" and will be "incapable of having
another relationship." Or, the belief may be
more evaluative in nature, as he may be convinced
that because of the breakup, "he is a bad person
and a loser." One of the primary differences
between REBT and other CBT models is the idea that
the beliefs are not just irrational, but also evaluative
in nature. Therefore, with a suicidal adolescent,
it is imperative to not only identify the irrational
beliefs, but also to determine the evaluative attributes
of these beliefs. In this particular example, the
irrational belief may be clear to the therapist;
however, the "I am a loser because she dumped
me" may not be as identifiable to the student.
"C," according to Dryden (1995), is the
adolescent's behavioral and/or emotional consequence
of B (irrational beliefs). Consistent with the example
of the male adolescent being dumped by his girlfriend,
he may become depressed, angry, or in this case
suicidal. As a clinician, it is also imperative
to be cognizant of the affective history of the
student as well as the other risk factors associated
with suicide. The clear advantage of REBT is the
ability to link the displayed emotion to the belief
and then to the activating event. With suicidal
adolescents, the model is easy to understand and
provides a linear model that is easy to understand
by both the clinician and the student. "D"
stands for disputation. Disputation is a method
of directly challenging the adolescent's irrational
beliefs (B), by requesting for empirical evidence
that he is a loser or he will be unable to have
another relationship. Inherent within disputation
is the idea of pragmatic empiricism. Here the therapist
attempts to help the adolescent identify his irrationality
surrounding the breakup as well as the idea of killing
himself. I use the term "pragmatic," because
disputation is direct and easy to comprehend, which
is especially important for children and/or adolescents.
For example, the therapist may ask the adolescent
what evidence exists that suggests he is a loser.
In addition, disputing the act of suicide would
be paramount in this particular circumstance. A
possible method of disputing the idea of suicide
would be to employ a didactic disputation strategy
(Walden et al. 1980). According to Walden et al.
(1980), "a second set of cognitive disputation
strategies are didactic, including the use of mini-lectures,
analogies, and parables. Lectures, as we suggested
earlier, are best kept brief and may be useful when
new ideas are being presented to the client (p.
163)." The lecture might revolve around suicide
and the repercussions that typically occur when
someone suicides. Obviously, there are other points
that could be made; nevertheless, in this situation
it would be important to educate the student about
the consequences of death. Some other possible methods
of disputing suicidal ideation may be to ask how
he would develop further relationships if he were
dead. Additionally, why does he need to have a relationship
with this girl if she is so "stupid" to
dump him? It would be important to point out that
suicide is an irrational response to a common adolescent
problem and that there are many other methods of
releasing or displaying his anger and/or sadness.
Disputation is unique to REBT and appears to be
responsible for subsequent behavioral/affective/cognitive
change. It differs from Beck's Socratic questioning,
as it is more direct, easier to follow and more
developmentally appropriate for adolescents. As
Albert Ellis (1999) stated, "...other forms
of therapy may help them feel better, but not get
better. The goal is to get better rather than feel
better. This is the goal of REBT (Lecture, 1999)."
This quote is extremely applicable to a suicidal
adolescent, as feeling better may not prevent suicide,
yet getting better, I believe, would. The final
element is "E," which stands for the effects
or consequences of D. While the literature is equivocal
regarding the clinical predictors of suicide, upon
psychological autopsies, hopelessness has been identified
as a common ingredient in many successful suicides
(Ellis & Newman, 1996). The utilization of disputation
is particularly important in this instance, as hopelessness
can be easily disputed.
According to Jamison (1999), "in short, when
people are suicidal, their thinking is paralyzed,
their options appear spare or nonexistent, their
mood is despairing, and hopelessness permeates their
entire mental domain (p. 93)." Therefore, a
possible disputation would be to point out to the
adolescent that he is in fact hopeful and this particular
event is simply a roadblock to bigger and better
things. A therapist could empirically demonstrate
to the adolescent that he would be missed if he
decided to suicide by assembling a group of teachers,
friends and family members who would corroborate
the therapist's didactic disputation. These individuals
could also confirm that he is likeable person who
would be missed if he decided to kill himself. While
there is insufficient research on REBT and its application
to suicidal adolescents, one study conducted by
Woods et al. (1991) found that adolescents contemplating
suicide were the result of beliefs and/or irrational
cognitions (originating with "B.")
Strengths and weaknesses of REBT with suicidal
adolescents
Some of the potential strengths of REBT and its
application to suicidal youths would be its simplicity.
REBT seems to be a model which takes into consideration,
developmental levels - an important ingredient when
working with teenagers. REBT, in some respect, may
not seem like psychotherapy from the teenager's
perspective, due to its direct approach, didactic
style, and reliance on empiricism. Where other models
of therapy come across as mysterious and intimidating
to teenagers, REBT is exactly the opposite.
Another strength of REBT, particularly for adolescents,
is its absence of moral and/or judgmental perspective.
For example, if a teenager commits a crime, the
expectation would be "you are a bad person."
An REBT therapist, on the other hand, would most
likely say, "you did commit a crime, yet this
does not mean you are a bad person." This approach
can be very reassuring to a teenager who is so accustomed
to being judged for what they do, rather than for
who they are. According to Boyd and Grieger (1986).
"…RET is hypothesized to exceed the effectiveness
of other cognitive-behavioral treatments by virtue
of promoting unconditional self-acceptance and reducing
‘secondary problems' such as self-criticism about
having problems (p. 146-161)." Finally, REBT
for an adolescent who may be contemplating suicide
is logical, pragmatic and employs techniques which
are developmentally congruent with the adolescent.
While there are many potential strengths to REBT,
unfortunately there do exist a few drawbacks.
Weinrach (1990) has indicated that REBT has the
capability of rubbing individuals the wrong way.
Another criticism, or to be more accurate, a misconception
regarding REBT, is its failure to discuss the emotionality
aspects of emotional disturbances (Garcia, 1977
; Satzberg, 1979). REBT has also been lambasted
for being a model for tough-minded individuals.
According to Ziegler (1990), "…the counseling
profession attracts primarily Tender-Minded students,
people who are warm, sensitive, and caring. Tender-Minded
counseling students are often threatened or alienated
by a theory that espouses, life is often unfair."
Admittedly, with a suicidal adolescent, the idea
that life is often unfair may not be the message
you want to send to someone who is holding the belief
that life "sucks." In A New Guide to Rational
Living, Ellis (1961) corroborates this idea that
he/she has a right to decide what to do with his/her
life. Surprisingly, Ellis (1961) suggests that one
address suicide forthrightly and also with the addition
of what Ellis refers to as causal humor. This type
of approach may or may not be effective with adolescents.
Yet, some may suggest it lacks the necessary degree
of empathy to efficiently work with suicidal patients.
Review of Outcome Studies on REBT
As stated earlier, the literature is not replete
regarding the application of REBT to suicidal adolescents.
Woods et al. (1991), which analyzed the cognitive
variables correlated to the contemplation of suicide
among adolescents, found that suicidal ideation
and emotional disturbance were associated with irrational
beliefs. Woods et. al, (1991) also found that "these
young people are emotionally distressed to the point
of contemplating suicide, not because of the A conditions
frequently cited by research in the sociological
model such as poverty, poor academic performance,
unemployment and divorce, nor by the A conditions
in the second part of a double-order problem, but
by the B cognitions reflecting the way they view
themselves, others, and the world in which they
live or may live" (p. 39-40). However, based
on my review of the literature, there was little
empirical research regarding the actual application
of REBT to individuals contemplating suicide.
Nonetheless, REBT has been shown to be an effective
treatment with many psychiatric conditions. In addition,
the application of REBT has held its own in psychotherapy
outcome studies (Haaga & Davison, 1989). More
importantly, REBT has been deemed to be effective
as to the prevention of psychopathology. Maultsby
et al., (1974) conducted a study whereby they assembled
two groups of emotionally disturbed of high school
students, one control group (no rational-emotive
course), and one group who received rational-emotive
course. Both groups were given several personality
inventories as well as the Maultsby Common Trait
Inventory (1974). Data from this study indicated
that the group who received the rational-emotive
course achieved positive results (Maultsby et al.
1974). Results suggested that REBT can be a useful
therapy in the prevention of psychopathology. Clearly,
the prevention component of REBT can and should
be applied to adolescent suicide and deserves further
investigation. While the effectiveness of REBT appears
to be unequivocal, further study will undoubtedly
produce research opposing such a treatment modality.
However, according to Solomon and Haaga (1995),
"we know that not everyone responds favorably
to specialized REBT."
Conclusion
Based on statistics produced by the National Institute
of Mental Health (1996), the ninth leading cause
of death in the U.S. was suicide. Among adolescents
(15-19), the numbers are shocking, as the ration
was 9.7/100,000. Keeping in mind these statistics,
it becomes paramount that all CBT models start to
aggressively address this clinical conundrum. As
stated earlier, although there is a dearth of research
pertaining to the risk factors and psychiatric comorbidity
pertaining to suicide, the actual application of
a particular CBT model appears to have been omitted.
Admittedly, this paper was not intended to be a
research-oriented paper; however, it is crucial
to point out that there was very little research
regarding REBT and its application to suicidal adolescents.
Based on the REBT outcome studies, there appears
to be an over-identification with conduct disorders,
while, unconsciously, neglecting one of the leading
killers of our youth - suicide. As a result, the
goal of every CBT and hybrid CBT model should be
to conduct rigorous research to effectively combat
this silent killer.
References
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(1986). Self-acceptance problems. In A. Ellis
& R.M. Grieger (Eds.), Handbook of rational-emotive
therapy (pp. 146-161). New York: Springer.
Dryden, W. (1995). Brief Rational-Emotive Behaviour
Therapy. New York: John Wiley & Sons.
Ellis, A. (1961). A New Guide to Rational Living.
California: Wilshire Book Company.
Ellis, A, & Bernard, E.M. (1983). An overview
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Ellis, A. (1999). Working with difficult adolesecents.
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