5 REBT Techniques, Exercises, and Worksheets
Ellis trained as a clinical psychologist but found the options for treating his patients lacking. His dissatisfaction with the results he was seeing drove him to develop his own brand of therapy that emphasized action instead of talk.
Read on to dive deeper into the theory behind REBT and look at some of the techniques and interventions that you might practice with this type of therapy.
Before you continue, we thought you might like to download our three Positive CBT Exercises for free . These science-based exercises will provide you with detailed insight into Positive CBT and give you the tools to apply it in your therapy or coaching.
This Article Contains:
A brief look at the theory, what techniques does rebt use, examples of rebt in action, common rebt questions, a look at rebt interventions, 3 rebt worksheets (incl. pdf), recommended books on the topic, a take-home message.
Rational Emotive Behavior Therapy is based on the idea that it is not the things that happen to us that cause our problems; it is our thoughts and thinking patterns that lead to the cognitive, emotional, and behavioral issues that challenge us (Dryden, David, & Ellis, 2010).
This idea is captured in the acronym ABC:
A – The activating event or adversity B – Our beliefs about the event, ourselves, and the world in general C – The consequences of our emotions and behaviors
Ellis believed that far too much emphasis was placed on the activating events and that most of the consequences were actually determined by our beliefs (Albert Ellis Institute, n.d.).
This was a significant shift from the prevailing ideas of the day, and it gave new hope to clients who were frustrated with their lack of results from traditional therapy; after all, if our beliefs are the real culprit rather than the events, then we have much more control over the consequences than we may have thought.
REBT practitioners believe there are two categories of cognition: hot and cold. Cold cognition refers to the way we initially think about and understand what happens to us, while hot cognitions are evaluations of our cold cognitions (Turner, 2016).
We don’t have much control over our cold cognitions, as those are formed early on and are generally not consciously understood; however, we can influence how we evaluate those cold cognitions.
Further, REBT distinguishes between healthy negative emotions (or HNEs) and unhealthy negative emotions (or UNEs). HNEs follow from adverse events that we approach with rational beliefs and adaptive behaviors, while UNEs stem from irrational beliefs and maladaptive behaviors (Turner, 2016). REBT aims to help clients reduce these irrational beliefs and replace them with rational beliefs.
Grounded in these innovative ideas, REBT was designed as a practical approach to help people learn techniques that would allow them to overcome their obstacles and cope with life’s challenges more effectively.
Cognitive restructuring techniques.
- Coping techniques (Raypole, 2018)
Each category of technique corresponds to part of the ABC model , giving clients techniques to use at each step.
Problem-solving techniques are intended to help clients address the A in the ABC model, addressing the activating event or adversity head on. Popular problem-solving methods include:
- Problem-solving skills
- Social skills
- Decision-making skills
- Conflict resolution skills
Cognitive restructuring techniques are focused on helping the client change irrational beliefs (Clark, 2013).
- Logical or rationalizing techniques
- Guided imagery and visualization
- Using humor and irony
- Exposing yourself to whatever you fear
- Disputing irrational beliefs
When a client can’t change the event and is struggling even though they are using rational thinking, coping techniques can help.
These techniques can include:
- Breathing exercises
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In a typical REBT session, the therapist will likely go over the “ABCs” with the client.
For example, here is a sample transcript from a session of REBT:
Client : I had a really difficult presentation at work this week, and I totally blew it.
Therapist : Tell me about it.
C: Well, I stumbled a little while presenting, and I just felt so stupid. In the end, there were tons of questions from management that I didn’t anticipate, and that makes me feel like I missed the mark on the whole presentation.
T: It sounds like you got your point across and engaged your audience, but maybe you didn’t give a perfect presentation. Why does that upset you so much?
C: I feel like I must not be a very good employee if I don’t hit the mark every time.
T: And so what if you don’t hit the mark every time?
C: I guess it’s not that big of a deal to miss the mark every once in a while.
T: We all make mistakes. It seems like it wasn’t giving an imperfect presentation that upset you; it was how you judged yourself afterward that made you feel down on yourself.
C: Yeah, I think you’re right. I shouldn’t feel so bad though; everyone makes mistakes.
At this point, the therapist will likely help the client come up with some statements based on their irrational belief that they must be perfect for every presentation. They might come up with statements like:
“I must ace my presentation, or I am a bad employee.” “I must be a model employee, or I have no value at all.” “I must present with ease, or I am incompetent.”
Next, the therapist will help the client explore some alternative beliefs, like:
“It’s okay to slip up sometimes.” “Making a mistake doesn’t mean I’m worthless.” “Even if I botch a presentation, I can still be a good employee overall.”
If you’re interested in seeing how the professionals apply the principles and techniques of REBT, check out this four-video series from Albert Ellis and his protégé Janet Wolfe.
Some of the most common questions in REBT relate to how it works and how it differs from other forms of therapy. For example, below are three common questions and the corresponding answers:
- Question: How can REBT help me?
- Answer: REBT can help you learn more about yourself and the irrational beliefs that are damaging you or holding you back, and it can teach you how to address these irrational beliefs when they crop up.
- Question: Will REBT keep me from feeling emotions?
- Answer: No, REBT will not keep you from feeling emotions; however, it will help you to recognize them, accept them, and respond to or cope with them in a healthier way.
- Question: Do I need to go every week? For how long?
- Answer: No, you do not need to go every week. You and your therapist can work out a schedule that works best for you. You might go every week at first, but every-other-week sessions and monthly sessions are also common. Sessions are usually between 30 and 60 minutes, but this is also dependent upon you and your therapist. Whatever works for you is a good length!
To dive even deeper into REBT, check out the Albert Ellis Institute’s Frequently Asked Questions section, where they tackle further questions like:
- I’ve heard that REBT tries to do away with negative emotions altogether by making people think logically and objectively. Is that true?
- But aren’t feelings such as anger and anxiety normal and appropriate?
- With all this emphasis on “me,” doesn’t REBT encourage selfishness?
- Does REBT force its own beliefs about what’s rational on people?
Rational emotive behavior therapy vs. cognitive therapy?
If you’re wondering how REBT is put into practice with clients, this section is for you. There are tons of resources out there for practitioners or those interested in trying the techniques for themselves.
Check out the activities, exercises, and worksheets listed below.
3 REBT activities and exercises
Imagine the Worst
Catastrophizing involves “worst-case” thinking and can be an extremely common cognitive distortion. Frequently, we fear the uncertainty of potential negative events, even despite a lack of objective facts to support their occurrence (Quartana, Campbell, & Edwards, 2009).
This can help them realize that:
- The worst-case scenario is unrealistic and thus unlikely to occur.
- Even if it did occur, the worst-case scenario will probably still be tolerable.
- In the event that it happens, they would still be able to manage the outcome and prevent it from becoming catastrophic.
Blown Out of All Proportion
This technique involves both imagery and humor, combining two of the cognitive restructuring techniques for maximum effectiveness. It builds on “worst-case imagery” for reasons that will become obvious.
In a session, the therapist would ask the client to imagine that the thing they fear happening the most actually happened. However, instead of allowing the client to visualize it realistically, the therapist will guide them in visualizing it to an extreme, blow entirely out of proportion (Froggatt, 2005).
When things are this exaggerated, they become funny. Laughing at their blown-up fears will help the client get control over them. This exercise isn’t right for every fear, but it can be extremely useful in many cases.
You’ll find this intervention, with examples, in the Imagine The Worst PDF above.
Disputing Irrational Beliefs (DIBS) Handout
One of the most popular cognitive restructuring techniques is called disputing irrational beliefs (DIBS) or simply disputing (Ellis, n.d.). The point of DIBS is to question yourself on some of your limiting or harmful beliefs and essentially “logic” them out of existence.
Here are the questions to ask yourself, outlined in our Disputing Irrational Beliefs Handout :
- What is the self-defeating irrational belief I would like to dispute and reduce?
- Am I able to support this belief with objective facts?
- What proof is there that this belief is false?
- Is there any proof that this belief is true?
- What is the worst possible outcome that could occur if I fail to get what I believe I must? What’s the worst possible outcome if I do get what I believe I mustn’t? What other negative things could happen to me?
- What positive things could I cause to happen if my undesirable scenarios pan out?
Although this technique can be highly effective for irrational beliefs, it will not always work for your deepest or long-held beliefs. These are harder to dispute but not impossible; Ellis recommends recording your irrational belief and several disputes to the belief, then listening to it repeatedly and even allowing your therapist, therapy group, or loved ones to listen to it with you.
This technique has been adapted from Techniques for Disputing Irrational Beliefs by the Albert Ellis Institute into a client handout (Ellis, n.d.). For a more detailed exercise, check out our Challenging Questions Worksheet below.
Worksheets can make a great addition to REBT for clients or a satisfactory substitute for therapy in people with milder issues.
Check out these three worksheets on REBT techniques below.
1. Increasing awareness of cognitive distortions
Although it’s not necessarily an REBT-exclusive technique, this worksheet can fit in nicely with an REBT focus. It guides the user through identifying the cognitive distortions (irrational beliefs) that they hold.
First, the worksheet lists 11 of the most common cognitive distortions:
- All-or-nothing thinking
- Discounting the positive
- Jumping to conclusions
- Mind reading
- Fortune telling
- Magnifying (catastrophizing) or minimizing
- Emotional reasoning
- Should statements
- Labeling and mislabeling
Once the user reads through the common cognitive distortions and some examples, they can move on to the worksheet. It’s split into three columns with instructions for each:
- Feelings – Write down what feelings you are experiencing; these can include emotions and physical sensations.
- Thoughts – Notice what thoughts are associated with your feelings and write those down here.
- Cognitive distortions – Analyze your thoughts; is there a cognitive distortion there, or are your thoughts rational?
Take a few minutes each day to complete a row in this worksheet for at least one week, and you will improve your ability to identify your irrational beliefs, which is the first step toward correcting them. You can find the Increasing Awareness of Cognitive Distortions worksheet in the Positive Psychology Toolkit© .
2. Leaving the Comfort Zone
This worksheet will help educate the user on the four zones and motivate them to step outside of the comfort zone.
First, it defines the four zones:
- Comfort zone : the space in which we feel safe and in control; things are easy, and we know what to do.
- Fear zone : an uncomfortable space marked by uncertainty; we don’t know what to expect or what to do.
- Learning zone : another uncomfortable space, but not as bad as the fear zone; we begin to acquire new skills and expand our comfort zone.
- Growth zone : when we stay in the learning zone long enough, it becomes the growth zone, where we become comfortable with our new skills and experience.
Next, it directs the user to identify a comfort zone situation. It should be something coming up that will require the user to step out of the comfort zone and into the fear zone.
Once the user has identified a situation, they are instructed to identify their personal signs of fear or symptoms of their experience with fear.
In addition to noting the signs of fear, the user should identify what they would lose out on by not stepping into the fear zone. What opportunities or new potential benefits would they miss out on?
Further, the user should note the long-term possibilities of staying in the learning zone. How might they transform as a person? What could they gain from being in this zone over time?
Finally, the user finishes the worksheet by reflecting on how they would feel about themselves if they stuck it out in the growth zone, and how it would affect their relationships with others.
This worksheet can help users reframe their thoughts about their fears and face them. You can find it in the Positive Psychology Toolkit© .
3. Challenging questions worksheet
This worksheet can help the user question their irrational beliefs and stop them in their tracks.
First, it lists 10 common irrational beliefs that users may recognize in themselves:
- I am only as good as what I achieve.
- If they don’t love me, then I’m worthless.
- Other people should follow the rules I know to be right.
- It’s not okay to have this feeling. I should just be happy.
- The problems in this relationship are all my fault/their fault.
- This situation is hopeless; nothing will ever improve.
- If this person doesn’t like me, then other people must feel the same way.
- I must be able to do it all; if I can’t, then there’s something wrong with me.
- My life is too hard. Life shouldn’t be this difficult and frustrating.
- Anger is not safe; I must not let myself get angry about this.
Then, it lists 12 challenging questions the user can use to confront their irrational belief:
- What is the evidence for or against this idea?
- Am I confusing habit with a fact?
- Are my interpretations of the situation too far removed from reality to be accurate?
- Am I thinking in all-or-nothing terms?
- Am I using words or phrases that are extreme or exaggerated like always , forever , never , need , should , must , can’t , and every time ?
- Am I taking selected examples out of context?
- Am I making excuses? I’m not afraid; I just don’t want to go out. The other people expect me to be perfect. I don’t want to make the call because I don’t have time.
- Is the source of information reliable?
- Am I thinking in terms of certainties instead of probabilities?
- Am I confusing a low probability with a high probability?
- Are my judgments based on feelings rather than facts?
- Am I focusing on irrelevant factors?
The worksheet leaves space for the user to pick one belief and four challenging questions to answer with a new, healthier perspective on the irrational belief.
Given the popularity of other types of therapies , REBT has not gained the mainstream recognition that it deserves for its realistic approach and practical techniques. As such, you won’t find as many books about it as you might for Cognitive-Behavioral Therapy or Dialectical Behavior Therapy, but there are some excellent options, including a few books from the founder himself.
Check out these books to learn more:
- How to Stubbornly Refuse to Make Yourself Miserable About Anything—Yes, Anything! by Albert Ellis (Available on Amazon )
- Rational Emotive Behavior Therapy: A Therapist’s Guide by Albert Ellis and Catharine MacLaren (Available on Amazon )
- A Guide to Rational Living by Albert Ellis and Robert A. Harper (Available on Amazon )
- A Primer on Rational Emotive Behavior Therapy by Windy Dryden, Raymond DiGiuseppe, and Michael Neenan (Available on Amazon )
- Rational Emotive Behavior Therapy (Therapies of Psychotherapy) by Albert Ellis and Debbie Joffe Ellis (Available on Amazon )
In this piece, we went over the basic ideas behind REBT, learned about the techniques used, and walked through a few sample exercises and activities. I hope you have a better understanding of this type of therapy and its potential to help those struggling with irrational thoughts and harmful beliefs.
What are your thoughts on REBT? Does it make sense to you? Do you believe that our thoughts about what happens to us are more important than what actually happens to us? Let us know in the comments.
Thanks for reading!
We hope you enjoyed reading this article. For more information, don’t forget to download our three Positive CBT Exercises for free .
- Albert Ellis Institute. (n.d.). Rational emotive behavior therapy . Retrieved from https://albertellis.org/rebt-cbt-therapy/
- Clark, D. A. (2013). Cognitive restructuring. In S. G. Hoffman, D. J. A. Dozois, W. Rief, & J. Smits (Eds.), The Wiley handbook of cognitive behavioral therapy (pp. 1–22). John Wiley & Sons.
- Dryden, W., David, D., & Ellis, A. (2010). Rational emotive behavior therapy. In K. S. Dobson (Ed.), Handbook of cognitive-behavioral therapies (3rd ed.) (pp. 226–276). Guilford Press
- Ellis, A. (n.d.). Techniques for disputing irrational beliefs. Retrieved from http://albertellis.org/rebt-pamphlets/Techniques-for-Disputing-Irrational-Beliefs.pdf
- Froggatt, W. (2005). A brief introduction to Rational Emotive Behavior Therapy . Rational.org. Retrieved from https://www.rational.org.nz/prof-docs/Intro-REBT.pdf
- Quartana, P. J., Campbell, C. M., & Edwards, R. R. (2009). Pain catastrophizing: A critical review. Expert Review of Neurotherapeutics , 9 (5), 745–758.
- Raypole, C. (2018). Rational emotive behavior therapy. Healthline. Retrieved from https://www.healthline.com/health/rational-emotive-behavior-therapy
- Turner, M. J. (2016). Rational emotive behavior therapy (REBT), irrational and rational beliefs, and the mental health of athletes. Frontiers in Psychology , 7 .
Share this article:
What our readers think.
The cognitive distortions mentioned in this article are typical of CBT rather than REBT. The latter has only four dysfunctional beliefs: demandingness, awfulizing, frustration intolerance and global negative rating of self, others, life, the world, and some add psychological processes.
Yes, that is absolutely right! Thank you for your feedback.
Kind regards, Julia | Community Manager
I thoroughly enjoyed the read. I made more sense to me and helping me to finish my course with ease. This article was very helpful
It’s always pleasure I love the content as a psychology student
I have been using this technique for 20 years in later life(I’m a pensioner) after a sad childhood. It helps with major life-long depression, even tho it gets tedious at times. It is well worth the slog!
Is there anything about Emotional Control Card?
While we do not discuss the Emotional Control Card technique here, this is highly relevant and useful as a ‘homework’ component of REBT.
For anyone wondering, the practice was put forward by Sklare, Taylor, and Hyland (1985) . They encouraged their clients/research participants to carry a wallet-sized card around with them which listed negative emotions in two columns: intense and mild .
When feeling overwhelmed by an intense emotion like ‘abandoned’ or ‘furious’, people were encouraged to engage in rational self-talk to change their emotional state to the corresponding mild version of that emotion (e.g., abandoned –> a bit unimportant; furious –> agitated).
It’s a useful technique that’s still used today. 🙂
– Nicole | Community Manager
From where can we download pdf of REBT worksheet ?
The PDF of the REBT Worksheet is available to members of the Positive Psychology Toolkit. You can learn more about this toolkit here .
that was great. it was usfull to me.
problem solving techniques really help me,thank you so much
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10 Rational Emotive Behavior Therapy (REBT) Exercises & Activities to do with your Clients
Albert Ellis developed Rational Emotive Behavior Therapy , commonly referred to as REBT, in the 1950s. REBT shares common concepts, and strategies with other humanistic therapies, however, there are a few distinct differences. As an example, Rational Emotive Behavioral Therapy differs in the way that cognitive distortions are approached. Additionally, Counselors and Therapists believe that helping clients think in a rational manner will improve their thoughts, emotions, and behaviors, therefore improving overall daily functioning (Seligman & Reichenberg, 2010). Keep reading to learn 10 REBT exercises and activities you can do with your clients.
As REBT has developed over the years, it has become more compatible with other therapeutic approaches including narrative therapy , constructivist therapy, and existential therapy (Seligman & Reichenberg, 2010). REBT Counselors and Therapists pay respect to each client’s background and viewpoints, with the exception of rigid patterns that can be hurtful or damaging to their client (Seligman & Reichenberg, 2010).
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When utilizing REBT with clients, Counselors and Therapists recognize changes in beliefs as progress, which often leads to a decrease in their overall level of distress (Seligman & Reichenberg, 2010). Counselors enable their clients to become more aware of their thoughts, emotions, and behaviors. However, more importantly, Counselors help clients learn strategies and skills that allow them to increase their ability to engage in rational thinking (Seligman & Reichenberg, 2010).
There are six steps associated with REBT that Counselors and Therapists follow (Seligman & Reichenberg, 2010):
- Identify the Client’s irrational beliefs
- Explore the negative consequences of their beliefs
- Disputing their irrational beliefs
- Replace their irrational beliefs with healthier and more rational beliefs
- A change in feelings occurs as a result of rational beliefs
- Behaviors then experience a positive shift as well
Mental Health Concerns That Can Benefit from REBT
Rational Emotive Behavioral Therapy is an empirically based therapeutic approach that can be helpful for a range of clients. This includes various presenting concerns and diagnoses, healthcare settings, and various populations of clients (Seligman & Reichenberg, 2010).
REBT can be utilized in group therapy, individual therapy, family sessions, couples counseling , and psychoeducation sessions (Seligman & Reichenberg, 2010).
Clients who are living with mild and moderately severe mental health concerns can benefit from Rational Emotive Behavior Therapy. This includes clients living with depressive disorders, anxiety disorders, adjustment disorders, anger and aggression difficulties, obsessiveness, and sexual difficulties (Seligman & Reichenberg, 2010). Additionally, REBT can be effective in some cases of substance use disorders and can be observed in a peer-led support group called SMART Recovery (Seligman & Reichenberg, 2010).
Rational Emotive Behavioral Therapy does ask clients to engage in homework activities outside of the session. For this reason, it is important to ensure that clients are knowledgeable of REBT and have accurate expectations for their engagement outside of therapy sessions. For some clients, this can create a barrier that would then limit their ability to experience the full range of clinical gains associated with REBT.
REBT Exercises & Activities to do with Clients
Rational Emotive Behavior exercises can be used inside of therapy sessions, and be used as homework assignments outside of sessions. When REBT activities are used as homework, this would be explored in the subsequent session after a routine check-in regarding old business, their overall level of distress and functioning, and any major changes since their last session (Seligman & Reichenberg, 2010).
Examples of Rational Emotive Behavior activities that can be used in a session include:
- ABCDEF is a structured plan that can be used in sessions to identify, assess, dispute, and modify beliefs. The acronym can be useful for both ourselves and our clients in remembering the steps to follow. Spend time reviewing the steps with your client, and walk through an example based on a current challenge they are experiencing. TherapyByPro has an REBT ABCDEF Worksheet available that can be used during homework assignments.
The acronym in length is as follows:
- A: Activating Event
- B: Belief about the activating event
- C: Consequences of the belief]
- D: Dispute the belief
- E: Effective
- F: New feelings and behaviors
- In order to do the work associated with REBT, our clients need to spend time exploring their thoughts and feelings. Without doing so, they may not know how to get to the beliefs that are leading to their distress. Asking your client to explore their thoughts and feelings is a cognitive strategy that can be given as a fluid homework assignment. Maybe your client would benefit from doing this as a journal entry, or possibly doing this internal exploration while going for a peaceful walk. Help your client determine how they would best engage in self-exploration, and use this as a homework assignment. Allow for time to follow up in their following session.
- When working with your client to identify unhealthy beliefs, many find it helpful to provide clients with a worksheet that offers examples of common unhealthy beliefs. TherapyByPro offers an REBT Irrational Belief Worksheet that can also be used to track rational beliefs that can be used to replace irrational beliefs. Encourage your client to be mindful of their beliefs outside of the session and to note any other beliefs that they found themselves having outside of the session.
- Out of all the relationships that our clients have, one of the most important relationships that they have is with themselves. The person that they talk to the most is themselves, so another good REBT exercise is to explore their self-talk. How our clients speak to themselves is a direct result of the beliefs they have about themselves, and has an undoubtable effect on their emotions and behaviors. Encourage your client to take notice of the self-talk they have and the impact it has on their feelings and behaviors. You can then explore the belief that their self-talk stems from, and see how they can tweak their self-talk to be healthier.
- TherapyByPro offers a Consequences Analysis Worksheet that can be used to walk through the different consequences that your client experiences for their irrational beliefs. This can be a helpful tool if your client is unable to see the full effect of their belief and to navigate what the best approach would be moving forward. After using the worksheet, check in with your client to review how they responded to their irrational beliefs and any changes they experienced regarding their typical consequences.
- Another cognitive strategy that can be used as an REBT activity would be to have your client develop a rational thought to replace an irrational one. Once that is done, ask your client to write their new thought repeatedly. Clients can verbalize the new thought in addition to writing it down. This exercise can be done in the session and continued outside of the session. Allow for time to follow up regarding your client’s experience with this exercise and any impact they observed on their feelings and behaviors.
- Emotional reasoning is an example of an unhealthy thinking pattern that can have a significant impact on an individual’s day-to-day life. TherapyByPro’s REBT Emotional Reasoning Worksheet can be used to help clients identify their extreme beliefs and rational beliefs for specific situations. This can help clients narrow down the extreme beliefs that are having the most significant impact on themselves.
- Relaxation techniques are often introduced to clients who are engaging in Rational Emotive Behavioral Therapy. This can include meditation, breathing exercises, visualization, and guided imagery. Spend time introducing your client to multiple relaxation techniques, and allow for time to practice some in session. This can be useful on techniques that can be challenging to use, or confusing to your client. Encourage your client to practice using these strategies outside of the session, both when they are in distress and when they are not. Allow for time to follow up regarding their experience and any shift in their thoughts, emotions, and feelings that they observed.
- Another unhealthy thinking pattern that our clients may be living with is jumping to conclusions and fortune-telling. The REBT Jumping to Conclusions and Fortune Telling Worksheet can be used to identify unhealthy beliefs that clients may have for certain situations, and rational beliefs that can be used in their replacement. Encourage clients to be mindful of the discussed beliefs outside of the session.
- For clients to manage their distress, they first need to learn about healthy coping skills . After you introduce your client to a variety of new coping skills they can use, an effective REBT exercise would be to work with them to create a challenging situation where they would then be able to practice using their new coping skills. As an example, if your client picks out their clothes in the evening for the next day, a challenge for them may be to wait until the morning to choose their outfit. Encourage your client to use their new coping skills during the created challenge, and allow for time in your next session to process their experience.
Final Thoughts On Choosing Activities for REBT
Thank you for reading our resource on 10 REBT exercises and activities you can do with your clients. REBT can be an effective therapeutic approach for clients who present to counseling with varying concerns. With plenty of supportive research, we know that this can be a helpful tool for clients who are struggling with certain concerns and are willing to practice skills and other strategies outside of therapy.
If you are interested in learning more about Rational Emotive Behavioral Therapy, we encourage you to look into continuing education courses and specialized training opportunities in your area.
TherapyByPro is an online mental health directory that connects mental health pros with clients in need. If you’re a mental health professional, you can Join our community and add your practice listing here . We have assessments, practice forms, and worksheet templates mental health professionals can use to streamline their practice. View all of our mental health worksheets here .
Seligman, L. & Reichenberg, L.W. (2010). Theories of counseling and psychotherapy: Systems, strategies, and skills (3 rd Edition, pp 251-269). Pearson Education, Inc.
Author: Kayla Loibl, MA, LMHC
Kayla is a Mental Health Counselor who earned her degree from Niagara University in Lewiston, New York. She has provided psychotherapy in a residential treatment program and an outpatient addiction treatment facility in New York as well as an inpatient addiction rehab in Ontario, Canada. She has experience working with individuals living with a variety of mental health concerns including depression , anxiety, bipolar disorder, borderline personality disorder , and trauma .
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Making use of homework to enhance therapeutic effectiveness
Broder, M. Making Optimal Use Of Homework To Enhance Your Therapeutic Effectiveness. Journal of Rational– Emotive & Cognitive-Behavior Therapy, Volume 17, Number 1, Spring 2000.
MAKING OPTIMAL USE OF HOMEWORK TO ENHANCE YOUR THERAPEUTIC EFFECTIVENESS
Michael S. Broder
Homework is a well-established yet extremely under-emphasized aspect of the Rational-Emotive/cognitive behavioral orientation. This article recognizes homework as being a very powerful tool that needs to be incorporated into treatment in order to make it more efficient and effective. The author presents numerous techniques that can be used with virtually any therapeutic approach to maximize the impact of therapy between sessions. They include audio and bibliotherapy, goal setting, SUD Scale, mood management, disputation, affirmations, mood diary, list making, guided imagery, visualization, relaxation and meditation techniques, exposure, and thought stopping techniques. The article concludes with a discussion of why clients display resistance to homework along with some approaches that can be taken to address this resistance.
The use of homework in psychotherapy is a well-established protocol of the Rational-Emotive/Cognitive Behavioral orientation and one of Albert Ellis’ many great contributions to the field. Trademark homework assignments include reading, forms of exposure to an anxious situation, making a decision, and taking a risk such as confronting someone or something more easily avoided (Ellis, 1962; 1996).
Homework empowers our clients to make and see progress on their own. To a great degree, homework can enable your client to become your collaborator in their treatment. Homework can also help you to assess your client’s motivation. After all, if you get an agreement to do a certain type of homework and at the next session it is not done, that can tell you much about a client’s motivation. And one area where most therapists agree is that a client’s level of motivation is one of the greatest predictors of whether treatment will be successful. Yet in most REBT and Cognitive Behavioral literature, homework remains quite underemphasized.
Homework can also be a great focusing tool. But only if it is clear, specific, measurable and doable. “Clear” means that you and your client are on the same page as to what the homework assignment involves; for example, what reading to do or whom to confront. “Specific” means that the homework assignment zeros in on your client’s problem in such a way that its relevancy is obvious to both of you. For example, if you were to assign as homework a relaxation exercise, there would be, hopefully, no question about the relationship between that assignment and the issues you are working on in therapy. “Measurable” means that both you and your client can objectively evaluate the extent to which the assignment was completed so there is no question as to what you mean when you ask if the reading was done or if the list was made. An assignment that is “doable” is one that can be completed by the client. In other words, its outcome depends only on the actions taken by the client and not necessarily on the agreement and! or cooperation of others. An example of a bad homework assignment would be to have the client agree to get a job or to get a date. Instead, you might encourage your client to send out a certain number of resumes or to approach an agreed upon number of people for a date. In these examples of homework, no one else’s agreement is necessary for your client to complete the assignment successfully. On the other hand, getting a job or a date requires the compliance of someone other than the client.
The main premise of homework is a recognition that real changes occur outside your office, not inside your office. In that spirit, I believe that work done by clients between therapy sessions is often as or more important as what is done in the session itself. The main challenge is to make homework as relevant and user-friendly as possible. Homework assignments need to be designed using the principle of successive approximation making sure that the step or steps assigned to be taken are not too large or too small, especially when you are dealing with difficult clients or AXIS II cases.
My personal preference is to have clients spend at least as much time doing homework as they spend in therapy. This is not an absolute or even an optimal amount, but a minimum guideline that I will generally discuss with each client. Another guideline is for you, the therapist, not to work harder than your client. All of us who have done therapy for any length of time know that this can be easier said than done, especially with some of Your more difficult cases. However, this is still a worthy goal.
In this article I offer a smorgasbord of ideas designed to help you do what you do more effectively by making maximum use of the 167 hours in between sessions as well as the therapy hour itself.
Here are a variety of techniques that you can use to engage your clients in between sessions. I will give a flavor for how they can be used as homework assignments with the understanding that they need to be tailored and fine-tuned to suit the Particular needs they are designed to address.
TECHNIQUES THAT CAN BE USED IN BETWEEN SESSIONS Bibliotherapy and Audiotherapy
Bibliotherapy is assigned reading that is specific to the issue that you are working on in treatment. Few would dispute that the right reading is a great tool; provided, of course, the client does the reading. There are many sources of good and relevant reading information that is available to address virtually any issue (Ellis, 1993). The main problem with bibliotherapy is that clients are not as likely to read as they are to use approaches that require less effort. In addition, different people read and comprehend their reading with considerable variation. Another consideration is that most self-help material is oriented toward women. This is because publishers have long recognized that women out-buy men by a margin of more than four-to-one in the category of bibliotherapy_ type (self, help) materials (Holm, 1998).
One of the best ways to address these bibliotherapy problems is by using audiotherapy or assigning clients to listen to appropriate audiotapes that reinforce the material covered in your session in between sessions_ I have found that audiotherapy is more effective than its bibliotherapy counterpart simply because people are way more likely to listen than to read. If a tape is one-hour long, it will take everyone regardless of his Or her skill level one hour to listen to it_ Also, self-help audiotape publishers. have found that men are as likely some cases more likely) to listen, as are women. In addition, both men and women can listen to audiotherapy assignments while driving cars, exercising or walking, and at other times when they mao the mood to take on one more activity-such as listening not distract them from what they are doing. Proper listening as reading) provides the repetition of information that can h malize the issue(s) they are working on, as well as a reinforce of what is being said and worked on in treatment. When us assigned correctly, audio therapy goes a long way to free the hour so that you may concentrate on resistance and other issue5 more unique to your client.
Repetition is an important aspect of teaching difficult info In my experience, an overwhelming number of clients are more to listen again and again to get that needed repetition than the~ read and reread bibliotherapy material.
For example, if self-evaluation is the issue, they need to learn in the session and by virtue of the homework they are assign whenever they engage in global rating as “I am no good,” an generalization is taking place (Broder, 1995). Then your client disputation and other cognitive restructuring techniques as mo vant.
Clients who are going through major changes need to learn t. and doubt is quite normal, while generally not desirable. Client are working on relationships and sexual issues need to unde~_ that many myths can cause dysfunction. For example, the m in a good relationship orgasms are simultaneous and automatic very dysfunction-causing (Broder, 1996). Where better can a learn that these myths could explain why they may negate sex doing reading or listening to material that makes these points to force what they have learned in their therapy sessions.
Sometimes the easiest part of therapy is communicating info and misinformation about an issue, but at the same time it can one of the most time-consuming parts of treatment. Many thera have trained and supervised over the years have confided that th . tired of going over the same points with client after client after and, therefore, find that they develop a tendency to avoid doing remember the function of biblio- and audio therapy is to give that mation that you the therapist may take for granted, to encourage tition of it, and to reinforce what you are teaching and working the session. Thus, audio- and bibliotherapy can be considered a e ine form of mentoring.
There are several other audiotherapy approaches you can employ.
Many therapists make up relaxation tapes for their clients as well as tapes on other topics. Another fine technique is to encourage your clients to tape their therapy sessions for re-listening. This can be done by bringing their own tape and tape recorder to therapy sessions. They keep the tapes to listen to, perhaps, several times in between sessions. This is a practice that can be quite helpful in getting clients to hear much of the things they “know intellectually” but need to learn on an emotional level. Repetition of this type is one excellent way to achieve a breakthrough with hard-to-integrate material. An often helpful follow-up to this approach is to give your client a short (but expected) “quiz” on things that were said during the previous session, based on the tape they produced in therapy and, hopefully, listened to in between sessions. Finally, there are many audiocassette programs that can be used for audiotherapy purposes. Over the past few years I developed a series of audiotherapy programs that incorporate numerous techniques into a series of self-contained homework assignments with reproducible exercise worksheets which I call The Therapist’s Assistant (Broder, 1995; 1996). This series was edited by Albert Ellis and is one of many resources at your disposal.
Covering all the steps and ramifications of goal setting and goal prioritizing is often impossible to do within the time constraints of a therapy session. Yet, it is an extremely important step in the therapeutic process. So having your client work on goals-whether or not they were goals established during your session-is a great use of homework time. This includes identifying all the important aspects of the goals-all of the Who, What, When, Where and Why questions. A basic goal-setting homework assignment exercise will have the client come into the next session with answers to all of these questions: What is the goal? What do you want to accomplish by reaching it? Who is it that can be involved in this besides you? That is, who, if anyone, can help you achieve it? When do you want it accomplished by? Where is it to take place? And most importantly, why do you want to achieve this goal anyway? Once your client’s issue or reason for being in therapy is defined and fine-tuned, then the goal (what the situation would be if that issue were resolved) needs to be just as finely tuned.
The next step in goal setting is to think about and write out a strategy or plan which is defined as the shortest route between Point A (the issue) and Point B (the goal); and then, lining up whatever support is needed to achieve the goal becomes the next homework step. This can be done at home; and is also excellent material for your next session.
When there are many goals, prioritizing them is important; and goal prioritizing is also an excellent homework assignment. For example, consider a client who has lost his job and presents with a multitude of therapeutic issues. He may be depressed, feel a lack of direction, be experiencing a low level of self-confidence, and be nervous about a job interview. You have a litany of presenting problems: depression, the self-evaluation problem, you may have to help him deal with what his choices are with respect to which career moves are next. There might also be performance anxiety about taking the job interviews, anger at the boss who let him go, and marital problems at home as a result of all those things all triggered by this crisis. So finding out where the most energy is by having your client prioritize those issues and goals is a very important step. Doing this as homework can afford your client the quiet introspection this task deserves.
As a part of goal setting, it is also helpful to have your client break each defined goal into manageable steps or sub-goals. For example, there may be several smaller goals that are necessary to reach before taking that first job interview. After all, pushing your client to go right for something that may be perceived as extremely anxiety-producing such as (in this case) a job interview could be quite an approximation error that results in avoidance or a setup for failure. So the sub-goals are smaller steps that can be defined and attempted between sessions. They are ripe for discussion at your next session.
The SUD Scale (Wolpe, 1991) is an excellent way of teaching your client to quantify his or her feelings. SUD is an acronym that stands for Subjective Units of Distress (discomfort or disturbance). It measures the degree of intensity of a particular feeling or reaction on a scale of zero to ten. If you were measuring anxiety, for instance, “zero” would be no anxiety at all. A SUD of “one” would be a very small degree of anxiety whereas a “ten” would be an extreme amount of anxiety.
This can certainly be used for a variety of applications during your session. But an effective homework assignment is to haveyour clients create a customized anxiety barometer by having them identify on the scale of zero to ten something that would help trigger each level of anxiety they could feel. For example, a SUD barometer for anxiety could look like this:
Level One. While sunbathing a rain cloud appears
Level Two. Being a little bit late for dinner reservations Level Three. Having to send food back to a restaurant Level Four. Getting caught in traffic jam
Level Five. Having a flat tire while in a rush
Level Six. Asking someone you find attractive out for date while there is a real chance of being turned down
Level Seven. Waiting outside the boss’ office when there is a possibility of being fired
Level Eight. Speaking to a large and intimidating audience
Level Nine. Waiting to hear a medical report that is potentially life-threatening
Level Ten. Driving a car that is swerving out of control toward an embankment
This is just one example of an anxiety barometer. As a homework assignment, I routinely have clients who talk about anger, depression, anxiety or guilt start keeping track of just how angry, anxious, depressed or guilty they feel during the week by identifying what their potential range of the emotion is. You will find this particularly helpful, for instance, with depressed clients who negate their progress whenever the slightest twinge of depression appears, even though they may have been depressed at an eight or nine when they first started to see you and are now down to perhaps a three or four. This is quite a significant change, but if they have the tendency to negate their progress, it may be difficult for them to keep their own perspective on how far they have come without using something like a SUD Scale to keep track of their depression at home.
You can also determine together at which SUD level it might be most appropriate for your client to approach a threatening situation. For example, in the case of the client who has lost his job and is in the process of readying himself for another job interview, you may be able to collaborate and establish a target level for anxiety on the SUD Scale as the optimal point at which he would be ready to commit to actually start taking job interviews. This approach is especially indicated for someone who has demonstrated a tendency to be characteristically avoidant. It can also be used in conjunction with several of the homework techniques to be discussed later in this article.
Mood management is teaching a client how to anticipate and then master a mood-when it occurs-instead of becoming overwhelmed by it. This can be used for feelings of anxiety, depression or virtually any other kind of mood situation. The first step with mood management is to have clients identify their internal triggers to the mood and then learn to see beyond them. In other words, clients need to ask themselves “What would be my situation if I could truly master this mood?” Next, clients can learn to work both during the session and at home to develop some strategies that can be employed when finding themselves in circumstances that will predictably trigger the mood. Then, by using mood-changing techniques at the appropriate moment such as certain breathing and posture exercises, they can learn a degree of empowerment over their moods.
One of my favorite mood management exercises that employs numerous techniques you can use as homework is called the “emotional fire drill” (Broder, 1992), where I have clients anticipate-that is, identify and visualize a dreaded situation (e.g., a job interview, asking someone out for a date, or giving a talk to a large intimidating audience). I ask them to imagine the situation going first the best possible way; and then to imagine it going the worst possible way. In so doing, clients can come to anticipate that in between the two extremes generally lay the reality. An emotional fire drill can be done several times a day as a way of rehearsing for an adverse situation and learning how to handle the emotion or emotions so that they in and of themselves don’t become the dreaded situation. Thus, the emotional fire drill technique helps clients to acknowledge and learn at the crucial time they need to know it, the fact that quite often it is their emotional reaction-often the discomfort anxiety-that is dreaded way more than the trigger itself.
Disputation is perhaps the most well-known and widely used classic staple of REBT (Ellis, 1962). Disputations are generally questions that you can ask clients or, in the case of homework, clients can ask themselves. The task here both in therapy sessions and as homework is to teach clients to challenge their own irrational beliefs identified both in and out of the session.
I often have clients come up with and make lists at home of new disputations for material discussed at the last session. These client created disputations can be used whenever the situation calls for it. An example of a disputational question is “How does falling off the wagon mean that I can’t stay sober?” If a client believes “People who divorce are losers,” a disputation question might be: “If I heard that for the first time today, would I believe it?” For clients who believe that their childhood has doomed them to a life of unhappiness, they need to learn to ask themselves-between sessions-“If I had perfect parents and the best childhood of anyone I know, how would I handle (fill in the blank) differently?” This gets them into the habit of first examining and then cross-examining their own errant thinking. A client who believes “My situation won’t improve,” needs to ask, “How do I know that?” “Is that what I would tell someone I really care about who is in the same predicament?” “If not, what would I advise?” The answer to these disputation questions might prompt you to assign the client as homework to make a list of things they would advise their children to do in that situation; and you will often see an entirely different level of wisdom come out.
Effective affirmations are both coping statements and rational beliefs. Something that I have clients do on a routine basis at home is to make lists of their affirmations or coping statements and then look at them several times a day, even when they are not especially feeling the need to. Learning an affirmation on a deep emotional level involves not only looking at it when they are troubled by the issue, but also when they are in a more neutral or positive frame of mind. Coping statements reinforce the notion that poor self-evaluation and low frustration tolerance, and so forth are merely thinking habits. One big advantage to clients of seeing problems as thinking habits is simply that most people acknowledge that habits can be changed. This notion is a much harder sell when clients believe they are dealing with traits instead of habits.
Any time your client says something like “I never thought of it that way” as an answer to a disputation, whatever it is that they have just thought about differently is an excellent addition to their list of affirmations to be studied and reviewed at home. Some other examples of affirmations include, “I don’t have to lose my temper when I’m angry,” “I can handle this,” “I can stand it” (whatever one’s unique “it” may be), “Failing at a task does not make me a failure,” “I don’t have to give into my cravings for (fill in the blanks),” and “These cravings will pass.” It can be very helpful for your clients to put their affirmations on index cards and keep them handy for those times during the week when they are in the mood or simply ready to learn and re-learn this information.
A mood diary is a written record of moods kept by the client between sessions. It can be quite helpful in identifying triggers for anxiety, anger and depression. For example, a well-kept mood diary used for anger management might contain the following information:
What triggered the angry feelings?
What am I telling myself about the trigger?
A rating of the feeling on that SUD Scale of 0 to lO?
Was my angry response to the situation helpful or harmful?
Was it really worth all the attention or energy that I expended to become enraged?
Was there anything I really could have done to make those things that triggered my anger different?
If I had it to do all over again, how would I react now?
How would I advise someone else I really cared about to react or respond in this or another similarly upsetting situation?
What could have been a response that would have disarmed me if I had acted the way my opponent did?
I generally instruct clients that we do not have to spend a great deal of session time with the details of their mood diary, since it is the triggers and patterns that are most important for us to focus on in their sessions. Still, some clients will have a need to go over their entire diary in great detail during the sessions. This is all quite negotiable, but once they begin and continue to keep their mood diary at home, a lot of the dynamics of their moods will become obvious to them.
Making lists is really a way of self-brainstorming. As homework, you can have clients make any number of lists such as “All the people who care about me,” “Things I am proud of,” “Things I can do to feel better when I’m tense,” or “A list of everything that is bothering me” (including every problem, then rank them in order as though they were totally independent of each other), then a “List of solutions.” They can refer to these lists when they are feeling isolated, lonely or depressed. If you work with single clients who believe that they can only be happy if they are in a relationship, have them make a list entitled “Twenty things I now avoid that I would be doing if I were in an ideal relationship.” They will be surprised to see that most of them can be done in one form or another either alone or with a member of their support group right now. I like long lists better than short lists because long lists challenge clients to really think. Using the analogy of exercise, I explain that the pushups one does at the very end of the set are the most beneficial ones. Encouraging clients to get beyond the things they normally think of makes the lists most helpful. And in between sessions is when they have the time to do this activity the most justice.
Another favorite list of mine to assign is “If I could do it all over again go back to age 18 or high school or when single or when married, and so on, (or whatever the hindsight-driven case may be)-what would I now do differently?” (and list twenty or more things). They will find once again that most of the entries on their list can be done in some form now. This particular exercise often helps clients to rediscover their passion while reducing their need to obsess about the past.
Guided imagery techniques such as Rational Emotive Imagery (Ellis, 1962) can be extremely powerful tools for you to teach clients to do at home. They stimulate client’s affectivity through suggestions that create imagined situations rich in therapeutic material.
You can make an imagery tape during the session of your voice that is tailored especially to clients’ issues for them to hear in the session and then re-listen to at home during the week. For example, you can have them imagine a very safe place, or becoming some other person in an interaction where they are having difficulties. If you use behavioral contingencies, you can use imagery to help them produce a list of pleasant images, such as touch or lying on a beach or a warm water effect; or unpleasant images such as loud noise, pain, rodents, or something they identify as being more specifically unpleasant. After awhile, they will begin to use these skills with very little difficulty.
One great advantage you have with audiotherapy is that the tape can actually become the therapist. Additionally, on the tape you can change the entire approach from a didactic to an experiential one. This is ideal for guided imagery between sessions. With guided imagery, you can introduce a trigger or create any situation you would as previously described with the emotional fire drill. For example, clients can create situations that may depress them on the O-to-10-SUD Scale at a nine or ten. You can then teach them how to use various mood-changing techniques to quickly reduce their feelings of depression down to a one or two. And this can be practiced over and over again at home.
A sister technique to imagery is visualization where clients visualize going to some desirable or undesirable endpoint and in their mind’s eye and then work backwards to the present. You can help your clients create a situation that would exist on the other side of the obstacles they are now facing. For example, a client feeling a great deal of anxiety about giving a talk can visualize getting a standing ovation after a superb speech.
If you are working with someone who is ending a love relationship, you can have him or her imagine themselves five years from the present with all of the emotional and practical issues now on the table, having been resolved. You can then help them to come up with a vision of what their situation might be at that blissful time five years hence. From that endpoint, you can work backwards to where they are now. If done well, the result can be a very viable set of goals and plans to get to that visualized endpoint. That is a time projection technique that combines visualization with goal setting and can be done in your office or completed at home with the exercise on tape.
Yet another variation of this technique that can be assigned as homework is to have your clients look ahead and ask “What would I do differently in my life if I had an unlimited amount of self-confidence?” Once completed, clients would then make a list of every possible answer to that question after thoroughly seeing themselves in that much improved state. If any of these visions get too difficult to do in between sessions, chances are they bring up a lot of material that is worth revisiting in the next therapy session with your help in getting through the obstacles encountered.
Relaxation and Meditation Techniques
There are many relaxation and meditation approaches clients can use in between sessions when they are anxious or stressed (Broder, 1993). Many are even available on tape. One very simple meditation technique you can teach your clients without any external props is for them to get into a comfortable posture, and with their eyes closed to think of the word “calm” while inhaling and the phrase let go on the exhale. The purpose of this is to teach clients to bring their relaxation response under their own control. This can be done for any length of time.
A more direct relaxation homework technique is (again with eyes used) for clients to count backwards from ten to one, telling themselves that at the count of one they will feel completely at peace, totally relaxed and that this relaxed state can be maintained for as long – they choose. For clients to return to an alert state, they can be instructed to count forward from one to five. At the count of five, they will be back to the present bringing the relaxation exercise to an end.
This is practiced on a daily basis-once, twice or three times a day they will soon master their relaxation response and will be able to use – practically any time as an on-the-spot technique at the first signs of stress or anxiety.
Exposure is a well-tested procedure of choice to help clients confront an anxiety-provoking situation. By using exposure properly, clients earn to hold their own feet to the fire. To avoid an approximation error (taking steps that are too big resulting in failure), it is often wise ~o use imagery, visualization and other types of rehearsal before clients actually confront in-vivo the “dreaded” situation. Getting to this step is usually an advanced goal of therapy. By this stage, clients are ready to attempt the job interview or get into the elevator (if that is ~hat the anxiety is about) or, perhaps, to face another situation which has been long-feared. For example, if you are dealing with single clients with loneliness issues who are dreading Christmas, New Year’s eve, Valentine’s Day, their birthdays, or even a Saturday night, you can teach them to face that situation head-on with the goal of finding the formula to turn it into a positive situation, or at the very least to prove to themselves that they need not fear those occasions because they can stand (though may not like) them. Clients can benefit from assignments such as going alone to a nice restaurant, to the ballet, to a wedding or to someplace where they have repeatedly felt they could not bear to be unless they were with some special person. A good attitude to teach them is the realization that if the exposure exercise goes better than they thought, that progress has obviously been made. But if older fears are realized, it is still a no-lose situation since they have taught themselves the valuable lesson that they can handle themselves even if they did not particularly enjoy themselves. This insight greatly lessens their fear in performing the behavior again.
Thought-stopping techniques are very effective ways of reinforcing the notion that certain negative emotions may merely be unwanted thoughts that you can learn to control (Beck et aI., 1979). A thought stopping technique is anything that interrupts the pattern or intensity of an unwanted thought. Physical activity such as exercise is often effective. The old rubber band technique where whenever clients begin to experience an unwanted thought a rubber band around their wrist is snapped, giving them a very small amount of quite harmless pain. Thinking about yelling aloud to oneself the word “stop” at the right moment can also interrupt irrational thinking. As well, clients can make a list of things that can be distracters, such as music or anything that will interrupt their negative thought process.
HOMEWORK RESISTANCE: CAUSES, CURES
What can you do with clients who do not complete agreed-upon homework assignments? The answer often lies in the very resistance to change that could be behind practically all of their therapeutic issues. Consider some of these possibilities: Perhaps, some of your homework assignments are too difficult and need to be more carefully fine-tuned. Have your “overly compliant” clients agreed to do more than they were able? Do your clients fully understand the benefits of doing homework? For example, it is possible that the rationale and importance of working on their issues between sessions has not been fully communicated. Are your clients’ non-compliance merely examples of some of the biggest reasons they are in treatment in the first place? For instance, extreme discomfort anxiety-where the issue is short-versus long-term gain-could be the saboteur in many areas. In the short-term, it may be much easier for some of your clients to avoid the immediate pain of change than to challenge themselves with the promise of reward. Likewise, for many discomfort dodgers, it is much easier in the short run to avoid doing the homework, even though in the long run the changes they are seeking in therapy may not be forthcoming. Chances are once you have identified this strand of resistance it will be related to the cause of the presenting problem itself as well as to the resistance to doing whatever it takes to resolve it.
Extremely poor self-evaluation is another possibility for clients failing to complete homework assignments. These clients may be saying to themselves that they are so ineffectual and hopeless that no matter what they do their feelings, circumstances and life will not change anyway. The issue here is hopelessness and helplessness and all the Pandora Boxes to which those issues lead. In these cases, smaller steps resulting in some success are usually called for.
Another factor that can undermine homework compliance is that of a higher order disturbance. Some clients resist solving the presenting problem because they unconsciously anticipate that the solution of one problem will trigger even more serious problems. For example, clients who resist assignments that will help them to become emotionally free of an ended love relationship, may already be fearing and thus avoiding what they have identified as the next logical step the fear of rejection in developing a new relationship. In other words, the presenting problem could merely represent what I have long called a comfortable state of, discomfort.”
With that in mind, here are some simple strategies you can employ immediately to make homework more of a staple in your treatment protocol:
Communicate the importance of homework as early in treatment as possible with emphasis on its benefits to your client.
If your sessions are limited, space them out in such a way as to make treatment as effective as possible by giving ample time to complete homework assignments and exercises. If you do that, make it clear that if your client runs into difficulty additional sessions can be scheduled. Make sure your client understands that sessions are precious commodities.
Give lots of feedback and positive reinforcement when it becomes apparent that homework was completed.
Help your client see how therapy supplements what is being done in between sessions as well as the reverse.
Use both positive and negative contingencies to shape the completion of homework assignments.
Begin sessions by following up on homework assignments. I have found this strategy to be quite helpful in staying focused on one issue at a time. By not following up, homework may be perceived by clients as not being very important. In addition, following up gives you a built-in opportunity to reinforce whatever progress has been made in between sessions.
When you teach clients to do homework you are also teaching them relapse prevention. Those same skills they have mastered in doing homework assignments are the very skills they will need to call upon when the process of life tests them, as it will, over and over again.
Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive Therapy of Depression. New York: Guilford.
Broder, M. (1995). The Therapist’s Assistant, Volume I. Philadelphia, PA: Media Psychology Associates (available through www.therapistsassistant.com).
Broder, M. (1996). The Therapist’s Assistant, Volume II (Relationship Series).
Philadelphia, PA: Media Psychology Associates (available through www. therapistsassistant.com).
Broder, M. (1993). Self-Actualization: Techniques for Achieving Your Full Potential (on cassette). Chicago, IL: Nightingale/Conant.
Broder, M. (1992). Positive Attitude Training: The Power of Cognitive-Behavioral Psychology (on cassette). Chicago, IL: Nightingale/Conant.
Ellis, A. (1962). Reason and Emotion in Psychotherapy. Secaucus, NJ: Citadel.
Ellis, A. (1993). The Advantages and Disadvantages of Self Help Therapy Materials. Professional Psychology: Research and Practice, Vol. 24, No.3, 335-339.
Ellis, A. (1996). Better, Deeper, and More Enduring Brief Therapy. New York:
Holm, K.C. (1997). Writer’s Market. Cincinnati, OR: Writer’s Digest Books, a Division of F&W Publications.
Wolpe, J. (1991). The Practice of Behavior Therapy (4th edition). New York:
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What Is Rational Emotive Behavior Therapy (REBT)?
Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."
Steven Gans, MD is board-certified in psychiatry and is an active supervisor, teacher, and mentor at Massachusetts General Hospital.
- How It Works
- Beliefs Addressed
- Factors to Consider
- Getting Started
Rational emotive behavior therapy (REBT) is a type of cognitive behavioral therapy (CBT) developed by psychologist Albert Ellis . REBT is an action-oriented approach that’s focused on helping people deal with irrational beliefs and learn how to manage their emotions , thoughts, and behaviors in a healthier, more realistic way.
When people hold irrational beliefs about themselves or the world, problems can result. REBT helps people recognize and alter those beliefs and negative thinking patterns in order to overcome psychological problems and mental distress.
How Rational Emotive Therapy Works
According to REBT, our cognition, emotions, and behavior are connected. In order to understand the impact of events and situations that people encounter throughout life, it’s essential to look at the beliefs people hold about these experiences and the emotions that arise as a result of those beliefs.
The main goal of REBT is to help people respond rationally to situations that would typically cause stress, depression, or other negative feelings. When faced with this type of situation in the future, the emotionally healthy response would be to realize that it is not realistic to expect success in every endeavor. All you can do is learn from the situation and move on.
Rational emotive behavior therapy operates under a few main beliefs. The three main beliefs of REBT are:
- You are worthy of self-acceptance no matter what even when you struggle or make mistakes; there is no need for shame or guilt.
- Others are also worthy of acceptance, even when their behavior involves something that you don’t like.
- Negative things will sometimes happen in life, and that doesn’t mean that things are happening in a way they shouldn’t be. Life is not positive all of the time, and there’s no rational reason to expect it to be.
A core concept of REBT is the ABC model. This model explains how, while we may blame external events for our unhappiness, it is our interpretation of these events that truly lies at the heart of our psychological distress.
"ABC" is an acronym for:
- A : Activating event, which is when something happens in the environment around you
- B : Belief, which describes your thoughts about the event or situation
- C : Consequence, which is your emotional response to your belief
During REBT, your therapist will help you learn how to apply the ABC model to your daily life.
If you’re feeling depressed due to a conflict in your relationship , for example, a rational emotive behavior therapist may help you identify the activating event for your problem before encouraging you to figure out which beliefs led to your negative feelings. They would then work with you to change those beliefs and, ultimately, your emotional response to the conflict.
Common Irrational Beliefs Addressed With REBT
An important step in the therapeutic process is recognizing the underlying beliefs that lead to psychological distress. In many cases, these are reflected as absolutes, as in "I must," "I should," or "I can’t."
Some of the most common irrational beliefs addressed in rational emotive behavior therapy include:
- Feeling excessively upset over other people’s mistakes or misconduct
- Believing that you must be perfectly competent and successful in everything to be valued and worthwhile
- Believing that you will be happier if you avoid life’s difficulties or challenges
- Feeling that you have no control over your own happiness; that your contentment and joy are dependent upon external forces
Holding unyielding beliefs like these makes it almost impossible to respond to activating situations in a psychologically healthy way. Possessing rigid expectations of ourselves and others only leads to disappointment, recrimination, regret, and anxiety.
Rational Emotive Behavior Therapy Techniques
A couple of different techniques can be used during rational emotive behavior therapy.
One step toward changing your beliefs is undergoing a process called disputation . Disputation is meant to teach you life-long skills to help you manage your emotional response and overall mental health.
During disputation, your therapist will challenge your irrational beliefs using direct methods. They may question your beliefs head-on, causing you to rethink them, or they could ask you to imagine another point of view that you haven’t considered before.
While each therapist may approach disputation differently, challenging your beliefs is part of the process. Ellis suggested that rather than simply being warm and supportive, therapists need to be blunt, honest, and logical in order to push people toward changing their thoughts and behaviors.
Targeting Emotional Responses
An important part of the REBT process is learning how to replace your irrational beliefs with healthier ones. This process can be daunting and upsetting, and it’s normal to feel some discomfort or to worry that you’ve made a mistake.
While REBT uses cognitive strategies, it focuses on emotions and behaviors as well. In addition to identifying and disputing irrational beliefs, therapists and clients also work together to target the emotional responses that accompany problematic thoughts.
Techniques that might be encouraged include:
- Guided imagery
Conditions REBT Can Help With
REBT has some data to support its benefit for a variety of conditions, including:
- Anxiety and distress
- Disruptive behavior in children
- Obsessive-compulsive disorder (OCD)
- Social anxiety disorder
- Psychotic symptoms
REBT has also shown promise in sports psychology , where it can be used to help athletes overcome irrational beliefs that may be negatively impacting their mental health and performance.
Benefits of Rational Emotive Behavior Therapy
When developing REBT, Ellis’s goal was to create an action-oriented approach to psychotherapy that produced results by helping people manage their emotions, cognitions, and behaviors. Indeed, research suggests that REBT is effective at reducing irrational beliefs and changing behavior.
We see the same results in sports psychology, where REBT can decrease irrational beliefs and reduce anxiety for athletes.
Overall, REBT offers several behavioral benefits, like:
- Reduced feelings of anger, anxiety, depression, and distress
- Improved health and quality of life
- Better school performance and social skills
Effectiveness of REBT
REBT has a wide range of potential applications. Because it’s focused on education and taking action, it may be effective for a variety of situations and mental health conditions. It may even lead to lasting change in those who undergo this form of therapy.
Burnout at School or Work
Researchers have studied the impact that REBT has on professional and academic performance. One 2018 study showed that this approach was effective in reducing symptoms of burnout for undergraduate students and continued to help even months after therapy concluded.
Another 2018 study showed similar results for nurses. Group REBT reduced their job-related stress and burnout while increasing their job satisfaction and commitment to their organization.
Depression and Anxiety
REBT may be effective in reducing symptoms for people with depression or anxiety. The positive effects also appear to last even after therapy ends.
REBT has also shown promising results for adolescents experiencing depression. This may be due to its emphasis on teaching techniques like:
- Identifying cognitive errors
- Challenging irrational beliefs
- Separating individuals from their behaviors
- Practicing acceptance
REBT is quickly gaining popularity as a treatment option for athletes who are experiencing mental health issues. It can be used to restore and maintain athletes’ mental health, helping them learn how to change their outlook and manage their emotions. This often improves their athletic performance, though the goal of REBT in sports psychology is to care for the athlete’s mental well-being first and foremost.
Factors to Consider With REBT
REBT can be a daunting process. For some, disputation may feel aggressive or confrontational, and facing irrational thought patterns can be difficult, as it’s not easy to accept these beliefs as unhealthy. The process of changing these thoughts can be even more challenging, as it may involve learning to let go of long-held beliefs.
REBT is meant to teach you life-long skills and, as such, it’s not a passive process. Your sessions may involve reading assignments and homework , and you’ll likely have to step out of your comfort zone to get the benefits of this form of therapy.
How to Get Started With Rational Emotive Behavior Therapy
To begin REBT, check with your doctor for any recommendations of local therapists or search for mental healthcare professionals who offer this approach either in person or online .
During your first session, your therapist will likely discuss your goals and the activating event (or events) that prompted you to seek treatment. They may want to delve into REBT techniques right away; this form of therapy is very active and focused, so your therapist is not likely to spend a lot of time on casual conversation.
Throughout your treatment, you will probably receive homework assignments to complete and new behaviors to experiment with. Your willingness to try out new beliefs and different behaviors will impact how beneficial REBT is for you.
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Turner MJ. Rational emotive behavior therapy (REBT), irrational and rational beliefs, and the mental health of athletes . Front Psychol . 2016;7:1423. doi:10.3389/fpsyg.2016.01423
Russo-Netzer P, Ameli M. Optimal sense-making and resilience in times of pandemic: Integrating rationality and meaning in psychotherapy . Front Psychol . 2021;12:772. doi:10.3389/fpsyg.2021.645926
Ellis A, Ellis DJ. Rational Emotive Behavior Therapy, Second Edition . Washington, DC; 2019. doi:10.1037/0000134-001
David D, Cotet C, Matu S, Mogoase C, Stefan S. 50 years of rational-emotive and cognitive-behavioral therapy: A systematic review and meta-analysis . J Clin Psychol . 2018;74(3):304-318. doi:10.1002/jclp.22514
Turner M, Barker JB. Examining the efficacy of rational-emotive behavior therapy (REBT) on irrational beliefs and anxiety in elite youth cricketers . J Appl Sport Psychol . 2013;25(1):131-147. doi:10.1080/10413200.2011.574311
Ogbuanya TC, Eseadi C, Orji CT, et al. Effect of rational-emotive behavior therapy program on the symptoms of burnout syndrome among undergraduate electronics work students in Nigeria . Psychol Rep . 2019;122(1):4-22. doi:10.1177/0033294117748587
Kim H-L, Yoon S-H. Effects of group rational emotive behavior therapy on the nurses’ job stress, burnout, job satisfaction, organizational commitment and turnover intention . J Korean Acad Nurs . 2018;48(4):432-442. doi:10.4040/jkan.2018.48.4.432
Zhaleh N, Zarbakhsh M, Faramarzi M, Branch AA. Effectiveness of rational-emotive behavior therapy on the level of depression among female adolescents . 2014;4(4):102-107 J Appl Environ Biol Sci .
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- Published: August 2013
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Rational Emotive Behavior Therapy (REBT)
Resource type, therapy tool.
Dysfunctional Thought Record
Functional Analysis With Intervention Planning
REBT Consequences Analysis Form
- Emotional disturbance in a nutshell download archived copy
- A brief introduction to Rational Emotive Behavior Therapy – Wayne Froggatt download archived copy
- Structured disputing of irrational beliefs – Windy Dryden download archived copy
- What is Rational Emotive Behavior Therapy (REBT)? Outlining the approach by considering the four elements of its name – Windy Dryden download archived copy
- REBT Network download
- REBT depression manual download archived copy
- First steps in using REBT in life coaching – Windy Dryden download archived copy
- Albert Ellis and Gloria – full counselling session youtube
- 21 ways to stop worrying – Albert Ellis youtube
- Substituting rational thinking for irrational thoughts – Albert Ellis youtube
- David, D. (2014). The Empirical Status of Rational Emotive Behavior Therapy (REBT) Theory & Practice. Therapy , 3 , 175-221 download archived copy
- Dryden, W. (2013). On rational beliefs in rational emotive behavior therapy: A theoretical perspective. Journal of Rational-Emotive & Cognitive-Behavior Therapy , 31 (1), 39-48 download archived copy
- Ellis, A. (1980). Rational-emotive therapy and cognitive behavior therapy: Similarities and differences. Cognitive Therapy and Research , 4 (4), 325-340 download archived copy
What Is Rational Emotive Behavior Therapy?
Assumptions of rebt.
- Most people consciously and unconsciously train themselves to be to some degree emotionally disturbed.
- People’s self-defeating cognitions, emotions, and behaviors are intrinsically and holistically connected.
- If they choose to do so, and work hard at modifying their thinking, feeling, and behaving, they can teach themselves to lead more satisfying lives.
- ‘I absolutely must perform well at important tasks and be approved by significant others—or else I am an inadequate person!’
- ‘Other people must absolutely treat me kindly, considerately, and fairly—or else they are bad individuals!’
- ‘Conditions under which I live absolutely must provide me with what I really want—or else my life is horrible, I can’t stand it, and the world’s a rotten place!’
- Ellis, A. (2002). Rational emotive behavior therapy. In M. Hersen & W. H. Sledge (Eds.), Encyclopedia of Psychotherapy, Volume 2 (pp. 483–487). Amsterdam, Netherlands: Academic Press.
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What is Rational Emotive Behavior Therapy (REBT)?
Olivia Guy-Evans, MSc
Associate Editor for Simply Psychology
BSc (Hons) Psychology, MSc Psychology of Education
Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.
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Saul Mcleod, PhD
BSc (Hons) Psychology, MRes, PhD, University of Manchester
Saul Mcleod, Ph.D., is a qualified psychology teacher with over 18 years experience of working in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.
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Rational emotive behavior therapy (REBT) is a type of psychotherapy introduced by Albert Ellis in the 1950s. It is an action-oriented approach focused on helping people deal with their irrational beliefs and learning how to manage their emotions, thoughts, and behaviors in a healthier and more realistic way.
REBT focuses mostly on the present to help someone understand how their perceptions of situations can cause emotional distress, leading to unhealthy actions and behaviors that interfere with their life goals.
Once identified, understood, and adjusted to more rational thoughts, this can help people develop better relationships and approaches to situations and events.
REBT can be particularly helpful for people living with a variety of issues, but especially those experiencing the following:
- Addictive behaviors
- Disorder eating habits
- Sleep problems
- Overwhelming feelings of anger, guilt, shame, or rage.
Although REBT is considered under the umbrella of cognitive behavioral therapy (CBT) , Albert Ellis was considered the pioneer of CBT, influential to Beck.
This therapy was originally called rational therapy until it went on to include emotion and behavior, taking into account these other fundamental components of the therapy.
REBT was developed as a departure from psychoanalysis, probably the most popular therapy at the time. Psychoanalysis was thought to be useful for making people feel better after getting everything off their chests.
However, Ellis questioned whether psychoanalysis helped people deal with the root cause of their problems or helped them feel better at all in the long term.
Ellis believed that humans are naturally goal-directed, but they are also self-defeating and irrational. He believed that most people are unaware that many of their thoughts about themselves are irrational and negatively affect how they behave in relationships and situations.
According to Ellis, these thoughts can result in people suffering negative emotions and engaging in self-destructive behaviors.
Ultimately, REBT recognizes that our cognition, emotions, and behavior are all connected, interacting and influencing each other.
Core principles of REBT
A core concept of REBT is the ABC model. This model explains how, while we may blame external events for our unhappiness, our perception of these events lies at the heart of psychological distress.
REBT is grounded in the idea that people generally want to do well and reach their goals.
However, sometimes, irrational thoughts and feelings get in the way of these goals. These beliefs are thought to influence how an individual perceives circumstances and events.
The ABC model is as follows:
- A – Activating – the activating event is when something happens in the environment that triggers a negative reaction or response.
- B – Belief – this describes the thoughts about the triggering event or situation, usually irrational thoughts about the activating event.
- C – Consequence – this is the emotional response to the belief, usually distressing emotions resulting from irrational thoughts or beliefs.
Irrational Beliefs Addressed By REBT
Below are some examples of irrational beliefs that may be addressed in REBT:
- “If I fail this exam, my life is ruined.”
- “If I don’t excel in every area of my life, I’m a complete failure.”
- “I must always be on top of everything; any slip-up is unacceptable.”
- “My partner didn’t respond to my text, so they must be mad at me.”
- “I messed up that presentation, just like I always do.”
- “My friend is in a bad mood, and I know it’s because of me.”
Holding irrational beliefs can make it almost impossible to respond to activating situations in a healthy way.
Unhealthy feelings of anxiety are often driven by rigid and extreme attitudes, characterized by phrases like “must,” “should,” “have to,” and “need to.” These attitudes can lead to intense negative emotions.
Goals Of REBT
In REBT, individuals learn to differentiate between healthy negative feelings, which can be constructive during challenging situations, and unhealthy feelings of anxiety. Healthy negative feelings can guide a person to take appropriate action or accept situations beyond their control.
REBT emphasizes personal responsibility for emotions and encourages the use of constructive language.
REBT helps individuals shift from blaming external circumstances for their distressing emotions to recognizing that their thoughts and beliefs are the primary drivers of those emotions.
During REBT, the therapist will help the client learn how to apply the ABC model to their daily lives. They work with the individual to change those beliefs and their emotional response to situations.
An important step in this process is recognizing the underlying beliefs that lead to psychological distress. In many cases, these come as absolutes such as ‘I must,’ ‘I should,’ and ‘I can’t’ statements.
The therapist will usually discourage people from using these statements as they are unhelpful and irrational.
Below are some of the techniques of REBT:
Problem-solving is intended to help the person address the A in the ABC model.
This involves addressing the activating event or adversity head-on. Some common problem-solving methods include:
- Teaching assertiveness
- Learning social skills
- Learning decision-making skills
- Learning conflict resolution skills
Cognitive restructuring focuses on helping the person to change their irrational beliefs with techniques such as:
- Rationalizing techniques
- Guided imagery and visualization
- Using humor
- Exposing yourself to the fear
The REBT therapist may also use disputation to challenge a client’s irrational beliefs.
This involves questioning the validity of these beliefs, asking for evidence, and exploring alternative, more rational perspectives.
The therapist helps the client see that their irrational beliefs are not based on facts and encourages them to adopt more rational, evidence-based thinking, which can lead to healthier emotional responses and behaviors.
Coping techniques are taught to be learned in situations where the person cannot change the event or is struggling even though they are using rational thinking. Some coping techniques include:
- Breathing exercises
The therapist will usually teach their clients three forms of acceptance:
- Unconditional self-acceptance – this is where the person recognizes that they have good and bad points – they are flawed, but this doesn’t make them any less worthy than another person.
- Unconditional other-acceptance – this is where the person recognizes that some people won’t treat them fairly, and there is no reason why everyone should treat them fairly. Although others will not treat them fairly, these people are no less worthy than any other person.
- Unconditional life-acceptance – this is where the person recognizes that life is not always going to go the way they want, and there is no reason why it must go the way they want. They learn to accept that they may experience some unpleasant things in life, but life itself is never awful and is usually always bearable.
Imagining the worst.
Often, people will catastrophize situations, meaning that they use worst-case thinking. Catastrophizing is a common cognitive distortion where people fear the uncertainty of potential negative events despite a lack of objective evidence to support this.
REBT therapists can encourage clients to imagine the worst-case scenario when attempting to avoid thinking about it for fear of becoming more anxious. Utilizing the worst-case scenario can help the client realize the following:
- The worst-case scenario is unrealistic and, therefore, unlikely to happen.
- Even if it did occur, the worst-case will probably still be tolerable.
- If the worst does happen, they would still be able to manage the outcomes and prevent them from becoming catastrophic.
Blown out of all proportion
This activity involves the use of imagery and humor to tackle irrational thoughts. The therapist will ask the client to imagine the thing they fear the most actually happening.
However, instead of encouraging them to visualize this realistically, the therapist will ask them to visualize it to an extreme level.
When their worst fears become exaggerated, they can become humorous. The idea is that laughing at blown-up fears will help the client get more control over them.
Disputing irrational beliefs (DIBS)
DIBS is one of the most popular cognitive restructuring techniques in which the therapist questions the client’s beliefs head-on, causing them to rethink them, or they could ask the client to imagine another point of view that they may not have considered before.
Rather than the therapist being warm and supportive all the time, Ellis suggests that therapists should sometimes be blunt and honest to push people toward challenging their thoughts.
Disputing is a skill that can be learned in the long term to help people manage their emotional responses and limit some of their harmful beliefs.
A DIBS activity may include writing down a core belief someone holds and then considering the following:
- Are there any objective facts to support this belief?
- What proof is there that this belief is true/false?
- What is the worst outcome that could occur?
Ellis recommended recording the irrational belief and then writing several statements to dispute this so the person can see more evidence suggesting their belief is false rather than true.
How Effective is REBT?
REBT has shown to be effective in addressing a variety of mental health conditions and situations as outlined below:
- REBT is effective in reducing attachment anxiety , psychological inflexibility, obsessive-compulsive disorder symptoms, and emotional dysregulation (Hoseini et al., 2013).
- REBT has lasting positive effects even after therapy has ended and is as effective as cognitive therapy and medication for treating depression (David et al., 2008).
- In an educational context, REBT group counseling has been found to reduce anxiety in school students compared to regular group counseling (Misdeni et al., 2019).
- REBT is effective in reducing academic stress for students, and its benefits persist for months after therapy concludes (Priya & Padmavathi, 2021).
- In the workplace, group REBT can reduce job-related stress and burnout while increasing job satisfaction and commitment (Kim & Yoon, 2018).
- In the realm of sports psychology , REBT is an effective treatment option for athletes experiencing mental health issues, helping them manage unhelpful beliefs, emotions, and anxiety (Turner, 2016).
Limitations of REBT
While REBT has evidence to support its efficacy, some limitations and critiques have been noted.
The confrontational style of disputing irrational beliefs directly is a major area of controversy. This approach could potentially re-traumatize clients who have experienced abuse or invalidation in the past.
The confrontational style may also not suit clients from certain cultural backgrounds who value indirect communication and humility.
Additionally, REBT could arguably simplify psychological distress too much by focusing only on irrational beliefs. Factors such as childhood experiences and trauma play an important role as well.
From a neuroscience perspective, it can be questioned whether REBT sufficiently addresses emotional processing in the limbic system of the brain. While REBT aims to change thoughts and behaviors, emotions may not change as easily. More research is still needed into the neurobiology of REBT.
Finally, REBT may feel less personalized than other therapies and provides manualized rather than individualized treatment.
Personal Experiences of REBT
Below are accounts of individuals’ experiences of REBT sessions:
REBT vs. CBT
Below are some of the main differences between REBT and CBT:
The choice between REBT and CBT depends on individual preferences, specific issues, and therapy goals. Both approaches share common principles but have distinct philosophical and practical differences.
The Therapeutic Relationship in REBT
A strong therapeutic relationship is important for the success of REBT. Because this approach can involve blunt, confrontational disputing of your irrational beliefs, having a solid bond and trust between you and the therapist is crucial.
The therapist must establish rapport and be sensitive in challenging you. The confrontational style is not intended to attack you but to question your harmful thought patterns. Still, this approach can feel aggressive if proper trust is not built between you and the therapist.
You must feel safe being vulnerable and opening up to the therapist. The therapist also needs to demonstrate competence, care, and integrity for you to feel respected and understood. When you feel this trust with the therapist, you will be more receptive to the direct disputation techniques.
A safe therapeutic alliance gives you the confidence to take risks in changing your beliefs and behaviors. The therapist also provides encouragement through this challenging REBT process. With a good relationship as a foundation, the confrontational approach can be an effective catalyst for change.
Getting the Most out of REBT
To optimize outcomes from REBT, your active engagement is vital. Being more open to change and willing to challenge your thoughts/behaviors means you’re likely to benefit more.
Completing homework assignments between sessions gives you the opportunity to apply REBT techniques to your daily life. This helps cement new thinking patterns. Attending all therapy sessions is also important so you can get the full scope of REBT – missed appointments disrupt the process.
You should be prepared to feel some discomfort – it’s never easy to acknowledge and let go of irrational beliefs that may have developed over a lifetime. But leaning into the confrontation and fully committing to the REBT process is key. Change is difficult, but very worthwhile when you and the therapist work together actively.
Do you need mental health support?
If you or a loved one are struggling with symptoms of an anxiety disorder, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline for information on support and treatment facilities in your area.
Contact the Samaritans for support and assistance from a trained counselor: https://www.samaritans.org/; email [email protected] .
Available 24 hours a day, 365 days a year (this number is FREE to call):
Rethink Mental Illness: rethink.org
0300 5000 927
David, D., Szentagotai, A., Lupu, V., & Cosman, D. (2008). Rational emotive behavior therapy, cognitive therapy, and medication in the treatment of major depressive disorder: a randomized clinical trial, posttreatment outcomes, and six‐month follow‐up. Journal of clinical psychology, 64(6), 728-746.
Hoseini, T. H. M., Vaziri, S., & Kashani, F. L. (2013). The Effect of REBT on Reducing Somatization Syndrome, Obsessive-Compulsive Disorder, and Interpersonal Sensitivity of Women living in Qom.
Kim, H. L., & Yoon, S. H. (2018). Effects of group rational emotive behavior therapy on the nurses’ job stress, burnout, job satisfaction, organizational commitment and turnover intention. Journal of Korean Academy of Nursing , 48 (4), 432-442.
Marsinun, R. (2016). The effectiveness of Rational Emotive Behavior (REB) counseling to reduce anxiety in facing student exams at SMPN 150 Jakarta. In Proceedings of the National Seminar Series (pp. 306-327).
Meaden, A. (2010). The experience of rational emotive behaviour therapy.
Misdeni, M., Syahniar, S., & Marjohan, M. (2019). The effectiveness of rational emotive behavior therapy approach using a group setting to overcome anxiety of students facing examinations. International Journal of Research in Counseling and Education, 3(2), 82-88.
Priya, S. S., & Padmavathi, P. (2021). Assess the effectiveness of rebt on academic stress Among Adolescent Girls. TNNMC Journal of Obstetrics and Gynaecological Nursing , 9 (2), 36-41.
Turner, M. J. (2016). Rational emotive behavior therapy (REBT), irrational and rational beliefs, and the mental health of athletes. Frontiers in psychology , 7 , 1423.
David, D., Cotet, C., Matu, S., Mogoase, C., & Stefan, S. (2018). 50 years of rational‐emotive and cognitive‐behavioral therapy: A systematic review and meta‐analysis. Journal of clinical psychology, 74(3), 304-318.
Russo-Netzer, P., & Ameli, M. Optimal Sense-Making and Resilience in Times of Pandemic: Integrating Rationality and Meaning in Psychotherapy.
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- 2. About Dr. Matweychuk
- 3. Dr. Ellis's Letter of Recommendation \\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\ Thank You Letter from Harvard University Scientists
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- 5. Rational Emotive Behavioral Weekly Zoom Conversation Hour No Charge to Attend to Learn REBT
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- 7. REBT Worksheets & Handouts for Downloading at No Charge
- 8. My Books
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- 11. A Conversation with Dr. Windy Dryden on REBT
- 12. Dr. Ellis Explains REBT Theory
- 13. Homework - Please read
- 13A. Essay on Psychotherapy
- 14. Video - Anger Management
- 15. Ask Dr. Matweychuk Your Question on REBT
- Featured Interviews - Dr. Matweychuk
- 16. Audio 1 - Listen, Learn, Practice
- 17. Audio 2 - Listen, Learn, Practice
- 18. Audio 3 - Dr. Ellis's Audios & Lectures
- 19. Audio 4 - REBT Self-Hypnosis for Stress & Anxiety - Relaxation Training
- 20. Stoicism & REBT - Video of Lecture by Dr. Matweychuk
- 21. Frequently Asked Questions
- 22. Why I Practice REBT - Video
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- 25. Ideas To Help You Function Well
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- 29. Blog: Self-Help Posts on REBT
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- 34. Books on REBT
- 35. Counseling for College Students
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- 37. Treatment of Anger & Rage
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- 38A. Procrastination & Public Speaking Anxiety - A Client's Experience with REBT Therapy
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Here are handouts and other written documents I use with my patients to help them better understand the core concepts of Rational Emotive Behavior Therapy. Please feel free to download and use on your own. REBT is a self-helping approach and these documents will help you help yourself. Handouts offered free of charge from the Albert Ellis Institute - Click Here
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Supporting Homework Compliance in Cognitive Behavioural Therapy: Essential Features of Mobile Apps
1 Discipline of Psychiatry, Department of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
2 Division of Youth Psychiatry, Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
3 Centre for Mobile Computing in Mental Health, Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
4 Department of Psychiatry, University of Toronto, Toronto, ON, Canada
Cognitive behavioral therapy (CBT) is one of the most effective psychotherapy modalities used to treat depression and anxiety disorders. Homework is an integral component of CBT, but homework compliance in CBT remains problematic in real-life practice. The popularization of the mobile phone with app capabilities (smartphone) presents a unique opportunity to enhance CBT homework compliance; however, there are no guidelines for designing mobile phone apps created for this purpose. Existing literature suggests 6 essential features of an optimal mobile app for maximizing CBT homework compliance: (1) therapy congruency, (2) fostering learning, (3) guiding therapy, (4) connection building, (5) emphasis on completion, and (6) population specificity. We expect that a well-designed mobile app incorporating these features should result in improved homework compliance and better outcomes for its users.
Homework Non-Compliance in CBT
Cognitive behavioral therapy (CBT) is an evidence-based psychotherapy that has gained significant acceptance and influence in the treatment of depressive and anxiety disorders and is recommended as a first-line treatment for both of these [ 1 , 2 ]. It has also been shown to be as effective as medications in the treatment of a number of psychiatric illnesses [ 3 - 6 ]. Homework is an important component of CBT; in the context of CBT, homework can be defined as “specific, structured, therapeutic activities that are routinely discussed in session, to be completed between sessions” [ 7 ]. Completion of homework assignments was emphasized in the conception of CBT by its creator, Aaron Beck [ 8 ]. Many types of homework are prescribed by CBT practitioners, including symptom logs, self-reflective journals, and specific structured activities like exposure and response prevention for obsessions and compulsions. These can be divided into the following 3 main categories: (1) psychoeducational homework, (2) self-assessment homework, and (3) modality-specific homework. Psychoeducation is an important component in the early stage of therapy. Reading materials are usually provided to educate the client on the symptomatology of the diagnosed illness, its etiology, as well as other treatment-relevant information. Self-assessment strategies, including monitoring one’s mood using thought records, teach the patients to recognize the interconnection between one’s feelings, thoughts, and behaviors [ 8 ]. For example, depressed patients may be asked to identify thinking errors in daily life and document the negative influences these maladaptive thinking patterns can produce on their behaviors. Various psychiatric disorders may require different types of modality-specific homework. For example, exposure to images of spiders is a treatment method specific to arachnophobia, an example of a “specific phobia” in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) [ 9 ]. Homework is strategically created by the therapist to correct and lessen the patient’s psychopathology. The purpose of these exercises is to allow the patients to practice and reinforce the skills learned in therapy sessions in real life.
Homework non-compliance is one of the top cited reasons for therapy failure in CBT [ 10 ] and has remained a persistent problem in the clinical practice. Surveys of practitioners have suggested rates of non-adherence in adult clients of approximately 20% to 50% [ 10 , 11 ] while adherence rates in adolescents have been reported to be approximately 50% [ 12 ]. Many barriers to homework compliance have been identified in the literature; to facilitate discussions, they can be divided into internal and external factors. Internal factors originate from a client’s own psychological environment while external ones are created by external influences. Internal factors that have been identified include lack of motivation to change the situation when experiencing negative feelings, the inability to identify automatic thoughts, disregard for the importance or relevance of the homework, and the need to see immediate results [ 12 - 14 ]. Various external factors have also been identified, including the effort associated with pen-and-paper homework formats, the inconvenience of completing homework because of the amount of time consumed, not understanding of the purpose of the homework, lack of instruction, and failure to anticipate potential difficulties in completing the homework [ 14 - 16 ]. There is strong evidence suggesting that homework compliance is integral to the efficacy of CBT in a variety of psychiatric illnesses. In the treatment of depression with CBT, homework compliance has been correlated with significant clinical improvement and shown to predict decreases in both subjective and objective measures of depressive symptoms [ 17 - 23 ]. Similarly, homework compliance is correlated with short-term and long-term improvement of symptoms in anxiety disorders, including generalized anxiety disorder (GAD), social anxiety disorder (SAD), hoarding, panic disorder, and post-traumatic stress disorder (PTSD) [ 17 , 24 - 32 ]. Fewer studies have been done on homework compliance in other psychiatric conditions, but better homework compliance has been correlated with significant reductions in pathological behaviors in psychotic disorders [ 33 , 34 ], cocaine dependence [ 35 , 36 ], and smoking [ 37 ]. Two meta-analyses further support the notion that greater homework adherence is associated with better treatment outcomes in depression, anxiety-related disorders, and substance use [ 38 , 39 ].
The Utility of Technology in Enhancing CBT Homework
Despite its demonstrated efficacy, access to CBT (as well as other forms of psychotherapy) remains difficult due to the limited number of practicing psychotherapists and the cost of therapy sessions [ 40 ]. With the rise of mass-market mobile communication devices such as the iPhone or other kinds of mobile devices with app capabilities (smartphones), new solutions are being sought that will use these devices to provide therapy to patients in a more cost-effective manner. Mobile phones with app capabilities are portable devices that combine features of a cellphone and a hand-held computer with the ability to wirelessly access the Internet. Over time, ownership of mobile phones in North America has grown [ 41 , 42 ] and progressively lower prices have further reduced barriers to their use and ownership [ 43 , 44 ]. As more and more people acquire mobile phones, the acceptance of and the demand for mobile health solutions have been on the rise [ 45 ]. Boschen (2008), in a review predating the popularization of the modern mobile phone, identified the unique features of the mobile telephone that made it a potentially suitable vehicle for adjunctive therapeutic applications: portability, acceptability, low initial cost, low maintenance cost, social penetration and ubiquity, “always on,” “always connected,” programmability, audio and video output, keypad and audio input, user-friendliness, and ease of use [ 46 ]. Over the last decade, modern mobile phones have supplanted the previous generation of mobile telephones; progressive increases in their computing power, ongoing advances in the software that they run and interact with (eg, JAVA, HTML5, etc.), common feature sets across different operating systems such as Google Inc.'s Android or Apple Inc.'s iOS, and adoption of common hardware elements across manufacturers (eg, touch screens, high-resolution cameras, etc) have enabled the development of platform-independent apps for mobile phones, or at least apps on different platforms with comparable functionality (eg, apps written for Apple's HealthKit or the apps written for Microsoft's HealthVault).
The popularization of the smartphone presents a unique opportunity to enhance CBT homework compliance using adjunctive therapeutic applications such that well-designed mobile software may be able to diminish barriers to CBT [ 40 ] by making CBT therapists' work more cost-effective. However, there are no guidelines and no existing research that directly address the design of mobile phone apps for this purpose. Given this gap in the literature, we searched MEDLINE (1946 to April 2015) and PsycINFO (1806 to April 2015) for all articles related to “cognitive behavioral therapy”, “homework”, “mobile applications” and “treatment compliance or adherence”, and reviewed articles related to (1) mobile technologies that address homework completion, (2) essential features of therapy, or (3) barriers to homework completion in CBT. In this article, we propose a collection of essential features for mobile phone-based apps that will optimally support homework compliance in CBT.
A Proposed List of Essential Features for Mobile Apps That Optimally Support CBT Homework Compliance
In order to be effective for patients and acceptable to therapists, an optimal mobile phone app to support CBT homework compliance should conform to the CBT model of homework while addressing barriers to homework compliance. Tompkins (2002) provides a comprehensive guideline on the appropriate ways to provide CBT homework such that homework should be meaningful, relevant to the central goals of therapy, salient to focus of the session, agreeable to both therapist and client, appropriate to sociocultural context, practiced in session to improve skill, doable, begin small, have a clear rationale, include written instructions, and include a backup plan with homework obstacles [ 47 ]. In addition, the therapist providing the homework needs to be curious, collaborative, reinforce all pro-homework behavior and successful homework completion, and emphasize completion over outcome [ 47 ]. By combining Tompkins' guidelines with the need to reduce barriers to homework compliance (as described above), we obtained the following list of 6 essential features that should be incorporated into mobile apps to maximize homework compliance: (1) congruency to therapy, (2) fostering learning, (3) guiding therapy, (4) building connections, (5) emphasizing completion, and (6) population specificity.
Congruency to Therapy
Any intervention in therapy needs to be relevant to the central goals of the therapy and salient to the focus of the therapeutic session. A mobile app is no exception; apps have to deliver useful content and be congruent to the therapy being delivered. There are different types of homework in CBT, including (1) psychoeducational homework; (2) self-assessment homework; and (3) modality-specific homework. Which types are assigned will depend on the nature of the illness being treated, the stage of treatment, and the specific target [ 48 ]. An effective app supporting homework compliance will need to be able to adjust its focus as the therapy progresses. Self-monitoring and psychoeducation are major components in the early stage of therapy. Thought records can be used in depression and anxiety while other disorders may require more specific tasks, such as initiating conversation with strangers in the treatment of SAD. Therefore, the treatment modules delivered via mobile phones should meet the specific needs of therapy at each stage of therapy, while also providing psychoeducation resources and self-monitoring capabilities.
While there are large amounts of health-related information on the Internet, the majority of information is not easily accessible to the users [ 49 ]. Mobile apps can enhance psychoeducation by delivering clear and concise psychoeducational information linked to the topics being covered in therapy. As psychoeducation is seen as a major component of mobile intervention [ 50 ], it has been incorporated into several mobile apps, some of which have been shown to be efficacious in treating various psychiatric conditions, including stress [ 51 ], anxiety and depression [ 52 ], eating disorders [ 53 ], PTSD [ 54 ], and obsessive compulsive disorder (OCD) [ 55 ]. For example, Mayo Clinic Anxiety Coach is a mobile phone app “designed to deliver CBT for anxiety disorders, including OCD” [ 55 ]. The app contains a psychoeducational module that teaches the user on “the use of the application, the cognitive-behavioral conceptualization of anxiety, descriptions of each anxiety disorder, explanations of CBT, and guidance for assessing other forms of treatment” [ 55 ]. The benefits of delivering psychoeducation via a mobile phone app are obvious: the psychoeducational information becomes portable and is easily accessed by the patient. Furthermore, the information is also curated and validated by proper healthcare authorities, which builds trust and reduces the potential for misinformation that can result from patient-directed Internet searches. However, psychoeducation on its own is not optimal. Mobile interventions that also incorporate symptom-tracking and self-help interventions have resulted in greater improvement when used for depression and anxiety symptoms than those that deliver only online psychoeducation [ 50 ].
In contrast to conventional, paper-based homework, mobile apps can support in-the-moment self-assessments by prompting the user to record self-report data about the user’s current state [ 56 ]. While information collected retrospectively using paper records can be adversely affected by recall biases [ 57 ], mobile apps enable the patient to document his or her thoughts and feelings as they occur, resulting in increased accuracy of the data [ 58 ]. Such self-assessment features are found in many mobile apps that have been shown to significantly improve symptoms in chronic pain [ 59 , 60 ], eating disorders [ 61 ], GAD [ 62 ], and OCD [ 55 ]. Continuing with the previous example, the Mayo Clinic Anxiety Coach offers a self-assessment module that “measures the frequency of anxiety symptoms” with a self-report Likert-type scale [ 55 ]. The app tracks users’ progress over time based on the self-assessment data; users reported liking the record of daily symptom severity scores that the application provides.
Evidence suggests that a variety of modality-specific homework assignments on mobile apps are effective, including relaxation practices, cognitive therapy, imaginal exposure in GAD and PTSD [ 54 , 57 ], multimedia solutions for skill learning and problem solving in children with disruptive behavior or anxiety disorders [ 63 ], relaxation and cognitive therapy in GAD [ 62 ], or self-monitoring via text messages (short message service, SMS) to therapists in bulimia nervosa [ 61 ]. Mayo Clinic Anxiety Coach, for example, has a treatment module for OCD that “guides patients through the use of exposure therapy” [ 55 ]; patients can use this to build their own fear hierarchies according to their unique diagnoses. Users reported liking the app because it contains modality-specific homework that can be tailored to their own needs. Novel formats, such as virtual reality apps to create immersive environments, have been experimented with as a tool for facilitating exposure in the treatment of anxiety disorders with mostly positive feedback [ 64 - 66 ]. Apps that provide elements of biofeedback (such as heart rate monitoring via colorimetry of users' faces using the mobile phone's camera), have recently begun to be deployed. So-called ”serious games,“ (ie, games developed for treatment purposes), are also showing promise in symptom improvement in certain cases [ 51 , 67 , 68 ].
Doing CBT homework properly requires time and effort. As noted above, any sense of inconvenience while doing the homework may hamper a patient’s motivation to complete the homework. While patients may appreciate the importance of doing homework, they often find the length of time spent and the lack of clear instructions discouraging, resulting in poor engagement rates [ 49 , 52 ]. Therefore, it makes sense that the tasks should be simple, short in duration to begin with, and include detailed instructions [ 47 ], since homework completion rates have been shown to be correlated with patients’ knowing exactly what to do [ 33 , 69 ]. Many apps incorporate text messaging-based services or personalized feedback to encourage dynamic interactions between the therapist and the client [ 59 ]. However, the types of homework delivered by these apps are fixed. An app that adapts the contents to the user’s progress in learning homework tasks would be more engaging and effective since therapy should be a flexible process by nature. Ideally, the app would monitor and analyze the user’s progress and adjust the homework's content and difficulty level accordingly. While the effectiveness of this type of app has not been studied, a similar app has been described in the literature for treating GAD [ 62 ]. This app, used in conjunction with group CBT, collected regular symptom rating self-reports from patients to track anxiety. Based on patients’ ratings, the app would respond with encouraging comments and invite patients to practice relaxation techniques or prompt the patient to complete specific built-in cognitive therapy modules if their anxiety exceeded a threshold rating. Despite the simple algorithm used to trigger interventions, use of the app with group CBT was found to be superior to group CBT alone.
Therapists have a number of important roles to play in guiding and motivating clients to complete homework. First, the therapist needs to address the rationale of the prescribed homework and work with the client in the development of the treatment plan [ 47 ]. Failure to do this has been identified as a barrier to homework compliance. Second, the therapist should allow the patient to practice the homework tasks during the therapy sessions [ 47 ] in order to build confidence and minimize internal barriers, such as the failing to identify automatic thoughts. Lastly, the therapist has to be collaborative, regularly reviewing homework progress and troubleshooting with the patients [ 47 , 70 ]; this can be done during or in between homework assignments, either in-person or remotely (ie, via voice or text messaging) [ 60 , 71 ].
Reviewing and troubleshooting homework has been seen as a natural opportunity for apps to augment the role of therapists. Individualized guidance and feedback on homework is found in many Internet-based or mobile apps that have been shown to be effective in treating conditions such as PTSD [ 72 ], OCD [ 55 ], chronic pain [ 59 , 60 ], depression and suicide ideation [ 71 ], and situational stress [ 73 ]. Moreover, providing a rationale for homework, ensuring understanding of homework tasks, reviewing homework, and troubleshooting with a therapist have each individually been identified as predictors of homework compliance in CBT [ 74 , 75 ]. However, despite incorporating a variety of features including self-monitoring, psychoeducation, scheduled reminders, and graphical feedback [ 52 ], automated apps with minimal therapist guidance have demonstrated elevated homework non-completion rates of up to 40%, which is less than ideal.
The effects of technology should not interfere with but rather encourage a patient’s ability to build meaningful connections with others [ 76 ]. The therapeutic alliance between the therapist and the client is the strongest predictor of therapeutic outcome [ 77 ] and has been suggested to predict level of homework compliance as well [ 78 ]. While there is no evidence so far to suggest that technology-based interventions have an adverse effect on the therapeutic alliance [ 79 , 80 ], this conclusion should not be generalized to novel technologies as their impact on therapeutic alliance has not been well studied [ 81 ].
An arguably more significant innovation attributable to technology has been its potential to allow patients to form online communities, which have been identified as useful for stigma reduction and constructive peer support systems [ 82 ]. Online or virtual communities provide patients with a greater ability to connect with others in similar situations or with similar conditions than would be possible physically. Internet-delivered CBT that includes a moderated discussion forum has been shown to significantly improve depression symptoms [ 83 ]. Furthermore, professional moderation of online communities increases users’ trust of the service [ 84 ]. Therefore, including social platforms and online forums in a mobile app may provide additional advantages over conventional approaches by allowing easier access to social support, fostering collaboration when completing homework, and enabling communication with therapists.
A patient’s need to see immediate symptomatic improvement is an impediment to homework compliance since the perception of slow progress can be discouraging to the user [ 35 ]. To address this issue, it is important for both therapists and mobile apps to emphasize homework completion over outcome [ 47 ]. While a therapist can urge the client to finish uncompleted homework during the therapy session to reinforce its importance [ 47 , 85 ], there is little a therapist can do in between therapy sessions to remind clients to complete homework. In contrast, a mobile app can, for example, provide ongoing graphical feedback on progress between sessions to motivate users [ 52 , 86 ], or employ automatic text message reminders, which have been demonstrated to significantly improve treatment adherence in medical illnesses [ 87 ]. These features have previously been incorporated into some technology-based apps for homework adherence when treating stress, depression, anxiety, and PTSD [ 52 , 54 , 88 ] with significant symptom improvement reported in one paper [ 71 ].
Homework apps should, where relevant or useful, explicitly be designed taking into account the specific characteristics of its target audience, including culture, gender, literacy, or educational levels (including learning or cognitive disabilities). One example of how culture-specific design features can be incorporated can be found in Journal to the West, a mobile app for stress management designed for the Chinese international students in the United States, which incorporates cultural features into its game design [ 89 ]. In this game, breathing activity is associated with the concept of “Qi” (natural energy) in accordance with Chinese traditions; the name of the game itself references to a famous Chinese novel and the gaming environment features inkwash and watercolor schemes of the East Asian style, making the experience feel more “natural” as reported by the users. A different approach to tailoring design is taken by the computer-based games described by Kiluk et al [ 68 ] that combine CBT techniques and multi-touch interface to teach the concepts of social collaboration and conversation to children with autism spectrum disorders. In these games, the touch screen surface offers simulated activities where children who have difficulties with peer engagement can collaborate to accomplish tasks. Children in this study demonstrated improvement in the ability to provide social solutions and better understanding of the concepts of collaboration. Although the population-specific design is intuitively appealing, the degree to which it can enhance homework compliance has yet to be investigated.
There are several additional issues specific to mobile apps that should be carefully considered when developing mobile apps for homework compliance. Because of screen sizes, input modes, the nature of electronic media, etc, standard CBT homework may need to be translated or modified to convert it into a format optimal for delivery via a mobile phone [ 47 ]. The inclusion of text messaging features remains controversial, in part because of concerns about client-therapist boundary issues outside the therapy sessions [ 90 ]. One potential solution is to use automated text messaging services to replace direct communication between the therapist and the client so the therapist can't be bombarded by abusive messages [ 52 , 61 , 91 , 92 ]. Privacy and security issues are also real concerns for the users of technology [ 93 ], although no privacy breaches related to text messaging or data security have been reported in studies on mobile apps so far [ 88 , 94 - 98 ]. Designers of mobile apps should ensure that any sensitive health-related or personal data is stored securely, whether on the mobile device or on a server.
Finally, while this paper focused on “essential” features of apps, this should not be misunderstood as an attempt to itemize all elements necessary for designing a successful piece of software. Good software design depends on many important elements that are beyond the scope of this paper, such as a well-designed user interface [ 99 ] that is cognitively efficient relative to its intended purpose [ 100 ] and which makes effective use of underlying hardware.
The popularization and proliferation of the mobile phone presents a distinct opportunity to enhance the success rate of CBT by addressing the pervasive issue of poor homework compliance. A variety of barriers exist in traditional, paper-based CBT homework that can significantly hamper clients’ motivation to complete homework as directed. The 6 essential features identified in this paper can each potentially enhance homework compliance. Therapy congruency focuses the features of the app on the central goal of therapy and fostering learning eases engagement in therapy by reducing barriers. Apps should help the therapist guide the client through therapy and not hinder the therapeutic process or interfere with patient’s building connections with others. It is crucial that homework completion be emphasized by the app, not just homework attempting. Population-specific issues should also be considered depending on the characteristics of targeted users.
As an example of how this applies in practice, “Mental Health Telemetry-Anxiety Disorders” (MHT-ANX) is a new mobile app developed by the Centre for Mobile Computing in Mental Health at Sunnybrook Health Sciences Centre in Toronto that helps patients monitor their anxiety symptoms using longitudinal self-report. The symptom log is therapy congruent to the practice of CBT since it promotes patients' awareness of their anxiety symptoms and the symptoms’ intensity. The simplicity of the app makes it easy for patients to learn to use, consistent with the need for fostering learning and increasing compliance. The MHT-ANX app was designed to share patient data with their clinicians, helping clinicians guide patients through therapy and more readily engage in discussion about symptom records, thus potentially enhancing the therapeutic relationship. Homework completion is emphasized both by automated text message reminders that the system sends and by questions presented by MHT-ANX that focus on how homework was done. While there are few population-specific design issues obvious at first glance in MHT-ANX, the focus groups conducted as part of our design process highlighted that our target group preferred greater privacy in our app rather than ease of sharing results via social media, and prioritized ease-of-use. While not yet formally assessed, reports from staff and early users suggest that MHT-ANX has been helpful for some patients with promoting homework compliance.
Limitations and Future Challenges
The feature list we have compiled is grounded in current technology; as technology evolves, this list may need to be revised. For example, as artificial intelligence [ 101 ] or emotional sensing [ 102 ] develops further, we would expect that software should be able to dynamically modify its approach to the user in response to users' evolving emotional states.
This paper presents our opinion on this topic, supported by a survey of associated literature. Our original intention was to write a review of the literature on essential features of apps supporting CBT homework compliance, but there was no literature to review. The essential features that are the focus of this article are summaries of key characteristics of mobile apps that are thought to improve homework compliance in CBT, but randomized trials assessing the impact of these apps on homework compliance have not yet been done. We would anticipate synergistic effects when homework-compliance apps are used in CBT (eg, if measures of progress collected from an app were used as feedback during therapy sessions to enhance motivation for doing further CBT work), but the actual impact and efficacy of therapy-oriented mobile apps cannot be predicted without proper investigation.
Conflicts of Interest: None declared.
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Table of Contents
List of REBT Worksheets (5+ Effective Exercises)
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This page displays REBT worksheets. Some of these REBT worksheets are made by ourselves while some are curated from reputable third party websites, after reviewing various reputable mental health websites and consulting numerous articles.
Rational Emotive Behavioral Therapy, abbreviated as REBT, is the approach by which faulty beliefs of an individual are replaced with logical and rational ones.
REBT was introduced by Albert Ellis with the aim of changing behaviors and emotions of individuals by substituting the old irrational beliefs with rational ones.
REBT Worksheet- ABC of REBT
The working of REBT can be explained by the ABC model.
This ABC model elaborates how a specific belief associated with an event can affect the behavior of an individual.
The ABC model was extended later on, with an addition of DEF components.
Objectives: To enable individuals to alter their beliefs for producing a different outcome.
Instructions: For each of the below mentioned events and belief, mention the consequence, disputied belief, different emotion and new feeling.
REBT Worksheet- Replacing Irrational Beliefs
REBT focuses on replacing faulty, irrational beliefs with logical ones. Change in belief system affects an individual’s emotional state as well as his behavior.
Objectives: To enable individuals to replace their irrational beliefs.
Instructions: Enlist the beliefs, which in your view, are faulty and irrational. Replace these beliefs with rational ones.
First one has been done for you.
REBT Worksheet- Eliminating the Word MUST
There are three ‘musts’ of irrational thinking which troubles people. These three musts need to be eliminated in order to prevent stressful conditions and to eradicate formation of faulty beliefs.
These three musts include; “If i am good I must get approval of others”, “Others must treat me the way i want to be treated” and “if they don’t treat me the way i want to be treated, they are bad and must be punished”.
Objectives: To train individuals to be able to remove musts and shoulds from their beliefs.
Instructions: Write statements, fulfillment of which is a must for you. Then rewrite those statements without the word must.
REBT Worksheet- Problem Solving with REBT
REBT enables individuals to solve their problems efficiently by acquiring positive attributes such as positive self-talk, assertiveness, coping skills and so on.
Ability to think in more than one way also assists individuals in tackling their problems.
Objectives: To enable individuals to resolve their issues efficiently.
Instructions: For each of the issues mentioned below, suggest ways by which they can be resolved.
REBT Worksheet- Cognitive Reconstruction
Cognitive reconstruction, as the name implies, is the process by which an individual’s cognitions are restructured.
Just like our beliefs, our cognitions also affect our behaviors.
Cognitive reconstruction aids in changing the thinking pattern of individuals by providing them with an ability to think in more than one way.
Objectives: To enable individuals to view a thing in more than one way.
Instructions: For each of the below listed cases, mention your immediate thought, then suggest cognitive reconstructions.
REBT Worksheet- Decatastrophizing
The term “decatastrophizing” was introduced in REBT by Albert Ellis.
Decatastrophizing is a cognitive reconstructing technique with the help of which cognitions of an individual are distorted.
In the technique the faulty, unjustified beliefs of an individual are distorted and replaced with logical ones.
Decatastrophizing is most commonly used for treating psychological illnesses such as anxiety and psychosis.
The worksheet “Decatastrophizing” can be downloaded from the site, psychology tools , through this link .
This worksheet consists of following questions:
1. What is the catastrophe I am worried about?
2. How likely is this event to happen?
3. How awful would it be if this did happen?
4. Just supposing the worst did happen, what would i do to cope?
5. What positive and reassuring thing do you want to say to yourself about the “catastrophe” now?
It is evident from the structure of questions that this worksheets assists individuals in exploring themselves, their strengths and their coping skills.
This worksheet aims to enable individuals to imagine the worst side of a catastrophe so they would be able to cope with it if it actually happens.
Imagining the worst of a situation and not ignoring its predicted consequences, enable the individuals to prepare themselves for the real event by adopting certain coping skills and strategies.
REBT Worksheet- Self Help Form
The self help form of REBT is a great source for challenging your irrational beliefs and replacing them with rational ones.
The self help REBT form enables individuals to brainstorm the activating events which are either catastrophizing , unfavorable, uncomfortable, self-destructive or unbearable.
Then it allows the individual to justify his beliefs, the reason why the individual is worrying about the beliefs, the chances of the occurrence of certain events associated with those beliefs and the individual’s reaction if those events did really occur.
Once the individual has attended to his irrational beliefs, he is asked to focus on rationalizing them by thinking in a positive way, by developing self-acceptance, by thinking he could tolerate things.
In this way he would be able to substitute rational beliefs in the place of irrational schemas, think logically and indulge into self constructive behaviors.
REBT aims to not only help shape cognitions of individuals but also their behaviors and emotions.
The REBT self-help form is a great source that enables individuals to change their cognitions by themselves.
This also enhances their problem solving skills. The REBT self help form can be accessed from the following link .
REBT Worksheet- 10 Forms of Twisted Thinking- And How to Replace Them
The worksheet- 10 forms of twisted thinking- and how to replace them gives a brief introduction to ten different kinds of thinking we commonly indulge in.
These twisted thinking styles give rise to irrational thinking and thus formation of irrational beliefs.
Each of these twisted thinking styles; all or none thinking, overgeneralization, negative mental filter, discounting the positive, jumping to conclusions (fortune telling, mind reading), magnification, emotional reasoning, should statements, labeling and blame/ self-blame, have different impact on an individual’s thinking patterns.
These twisted thinking styles can be replaced with rational thinking in various ways, some of which have been mentioned in the table below.
This worksheet can be used as a guide to identify which twisted thinking style do you follow and aids in monitoring your thinking patterns.
Logical thinking and positive thinking help eradicate negativity and irrational thinking.
The original worksheet can be accessed through the link.
This worksheet is based on “The feeling good handbook” by David D. Burns.
REBT Worksheet- Checklist of Cognitive Distortions
The checklist of cognitive distortions gives an introduction to twisted thinking patterns to aid individuals in identifying their way of thinking.
This can help in identifying the area of correction.
For example if an individual indulges in ‘mental filter’ thinking pattern, he needs to work on analyzing and appreciating his positive qualities.
The twisted thinking patterns include:
1. All or nothing thinking: You look at things in absolute, black and white categories.
2. Overgeneralization: You view a negative event as a never-ending pattern of defeat.
3. Mental Filter: You dwell on the negatives and ignore the positives.
4. Discounting the positives: You insist that your accomplishments or positive qualities “don’t count”.
5. Jumping to conclusions: (A) Mind reading – you assume that people are reacting negatively to you when there’s no definite evidence for this; (B) Fortune Telling – you arbitrarily predict things will turn out badly.
6. Magnification or Minimization: You blow things way out of proportion or you shrink their importance inappropriately.
7. Emotional Reasoning: You reason from how you feel: “I feel like an idiot, so I really must be one.” Or “I don’t feel like doing this, so I’ll put it off.”
8. “Should Statements”: You criticize yourself or other people with “Shoulds” or “Shouldn’ts.” “Musts,” “Oughts,” “Have tos” are similar offenders.
9. Labeling: You identify with your shortcomings. Instead of saying, “I made a mistake,” you tell yourself, “I’m a jerk,” or “a fool,” or “a loser.”
10. Personalization and Blame: You blame yourself for something you weren’t entirely responsible for, or you blame other people and overlook ways that your own attitudes and behavior might contribute to a problem.
This worksheet is derived from the “The feeling good handbook” by David D. Burns. It can be accessed through the link.
Some of the above mentioned worksheets have been created by us while some of them have been curated from reputable third party websites.
These REBT worksheets aim to assist you in substituting your irrational beliefs and schemas with logical ones.
They also enhance problem solving skills in you.
If you have any questions or queries regarding these REBT worksheets, let us know.
We will be glad to assist you.
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- Published: 21 July 2021
Rational Emotive Behavior Therapy Compared to Client-Centered Therapy for Outpatients: A Randomized Clinical Trial with a Three Months Follow up
- Murat Artiran ORCID: orcid.org/0000-0003-1996-024X 1 &
- Raymond DiGiuseppe ORCID: orcid.org/0000-0003-2206-6361 2 , 3
Journal of Rational-Emotive & Cognitive-Behavior Therapy volume 40 , pages 206–233 ( 2022 ) Cite this article
This study evaluated the effectiveness of Rational Emotive Behavior Therapy (REBT) for outpatients with GAD and mild depression and tested the effectiveness of REBT to an active, alternative treatment, Humanistic, Client-Centered Therapy (HCCT) in a clinical setting. The study aimed to understand whether REBT is a more effective treatment than HCCT through testing both pre-treatment and including three-month follow-up results. Thirty-one participants were assessed for overall psychopathological variables such as anxiety, depression, levels of unhealthy negative emotions and regret, activation, hope and nothingness as ontological well-being (OWB) variables before and after a 12 week intervention as well as during a three-month follow-up. We randomly assigned participants to either REBT or HCCT. The psychotherapists followed strict guidelines to incorporate the distinctive features of REBT. This included educating clients about irrational and rational beliefs, introducing the binary model of emotional distress, using a range of disputing techniques (logical, philosophic, and functional), and discussing alternative rational beliefs such as unconditional acceptance of self, others, and life. The HCCT group was treated with Rogerian techniques such as unconditional positive regard, accepting negative emotions, and reflection. The clients completed the Beck Depression Inventory, Beck Anxiety Inventory, Shortened Attitude and Beliefs Scale, the Ontological Well-being Scale, and the healthy and unhealthy negative emotions scale. The outcomes were analyzed using split plot ANOVA with post hoc, Reliable Change Index, and Clinical Significance Change Index. Although split-plot ANOVA results showed that there was not significant difference in main effect of treatment between REBT and HCCT groups, further detailed analysis such as main effect of time, time by interaction values, Reliable Change Indices, clinically significant change analysis, and post hoc indicated that REBT treatment was more beneficial than HCCT treatment at any of the three time points in most variables. Another experimental study with larger sample is needed to confirm the result in future studies.
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Artiran, M., DiGiuseppe, R. Rational Emotive Behavior Therapy Compared to Client-Centered Therapy for Outpatients: A Randomized Clinical Trial with a Three Months Follow up. J Rat-Emo Cognitive-Behav Ther 40 , 206–233 (2022). https://doi.org/10.1007/s10942-021-00408-0
Accepted : 10 July 2021
Published : 21 July 2021
Issue Date : June 2022
DOI : https://doi.org/10.1007/s10942-021-00408-0
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