Cognitive Therapy for Obsessive Compulsive Disorder

ALBERT ELLIS ; Psychotherapist who preached a rational, behavioural approach http://www.highbeam.com/doc/1P2-

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COUNSELING IN SCHOOLS. A RATIONAL EMOTIVE BEHAVIOR THERAPY (REBT) BASED INTERVENTION - A PILOT
STUDY –

Assessing self-concept in children: Variations

across self-concept domains
From:
Merrill - Palmer Quarterly
Date:
October 1, 1999
Author:
Ditner, Elise; LeMare, Lucy; Woody, Erik Z; Hymel, Shelley
More results for:
self esteem AND rebt OR self concept

Multidimensional models of self, emphasizing variations in self-perceptions

across areas of one's life, have led to new, domain-specific self-report
measures. Two of the most widely used multidimensional self-concept
questionnaires were compared in Study 1 in a sample of 277 preadolescents.
The two measures were highly correlated and comparable in reliability,
stability, subscale interrelations, and associations with others' evaluations. In
Study 2 a wider variety of self-assessments (interviews, questionnaires, self-
ratings) across domains were compared in a sample of 161 preadolescents.
Results indicated that the correspondence among different self-assessment
approaches as well as between self and others' perceptions varied as a
function of the domain tapped. The observed domain variation may relate to
the type of information children use to evaluate their competencies across
domains.

For decades, psychologists have attempted to devise reliable and valid

means of assessing childrens' concept of self. Despite these efforts, the
assessment of the self-system has remained an elusive task. In her critical
reviews of this literature, Wylie (1961; 1974; 1979; 1989) has repeatedly
cautioned researchers about the problems inherent in attempting to assess
the self. Nevertheless, efforts have continued in this regard.

With the resurgence of interest in the self-system in the late 1970s and early
1980s (see Harter, 1983; Leahy, 1985; Suls & Greenwald, 1985) came a
notable shift from emphasis on the self as a generalized, unitary construct to
increased recognition that self-perceptions vary across the domains of one's
life (Damon & Hart, 1982; Harter, 1982, 1983; Marsh, Smith, & Barnes, 1983;
Shavelson, Hubner, & Stanton, 1976). Consistent with a multidimensional
view of self, researchers devised a new wave of domain-specific self-report
instruments to assess children's self-concept within particular content
areas, in addition to general self-worth (e.g., Harter, 1982; 1985; Marsh et
al., 1983; see Byrne, 1996; Wylie, 1989, for reviews). The psychometric
quality of these multidimensional measures has been well documented
(Byrne, 1996; Wylie, 1989), but the area is still plagued with concerns about
how to best tap children's self-perceptions and what different measures tell
us about children's self-knowledge.

In particular, little is known about the correspondence among domain-specific

self-concept data gathered with different methods and measures. Although
a few studies (to be reviewed) have compared the most commonly used
multidimensional self-concept measures, data are lacking on the stability of
domain-specific measures of self and on the relations between domain-
specific self-assessments and others' impressions of the child within those
domains. Such information has practical implications for researchers
concerned with instrument selection as well as conceptual implications
regarding the nature of children's self-knowledge. Do children see
themselves as others see them or are their self-perceptions distorted or
idiosyncratic? Are inconsistencies more likely in some domains than in
others? Is there a systematic pattern to these inconsistencies?

To address these issues, two studies were conducted to evaluate the utility
and comparability of domain-specific evaluations of self among
preadolescent, elementary school-age children. In the first study, two of the
most widely used multidimensional measures of children's self-concept were
compared in terms of reliability, validity, and stability, as well as
correspondence across common domains. In the second study, children's
self-perceptions in four major areas (peer relations, schoolwork, appearance,
and physical/athletic ability) were further examined to determine (a) the
correspondence among various types of domain-specific, self-report
approaches (questionnaires, ratings, interview data), (b) the correspondence
between self and others' perceptions of the child's performance in those
domains, and (c) the information children report using to evaluate
themselves in each domain.

STUDY 1

Two of the most widely used multidimensional measures of children's self-

concept are the Self-Description Questionnaire (SDQ-1) developed by Marsh
and his colleagues (Marsh, 1988; Marsh et al., 1983) and the Self-Perception
Profile for Children (SPPC) developed by Harter (1982, 1985). Both were
created for use with middle to later elementary children, Grades 3/4 to 6,
ages 8-12 years. In addition, both scales demonstrate excellent psychometric
qualities (see Byrne, 1996; Wylie, 1989). There is considerable overlap
regarding the areas tapped by the two scales, with each assessing the
domains of academic competence, physical/athletic competence, peer
relations, and appearance, as well as overall self-worth. In addition, the SPPC
assesses perceived behavioral conduct, whereas the SDQ-1 assesses parent
relations and provides for separate evaluations of competence in
mathematics and reading.
An important distinction between the two measures involves the wording of
items and the response format employed. The SDQ-1 provides children with a
series of statements (76 items) about their competency (abilities) and affect
(liking, interest) in various domains (e.g., "t am good at school subjects," "I
look forward to all school subjects," see Marsh, this volume, for a discussion
of the competence/affect distinction). For each statement children indicate on
a 5-point scale the degree to which the statement is true of themselves.
Although one negatively-- worded item is included for each domain as a
response check, each subscale score is based on a sum of eight positively-
worded items. The SPPC provides students with a series of logically-opposed
statements (36 items, 6 items per subscale) regarding competency in a
particular domain (e.g., "Some kids feel that they are very good at their
school work, BUT other kids worry about whether or not they can do the
schoolwork assigned to them"). The child must decide (a) which statement
best describes him/herself and (b) whether the chosen statement is sort of or
really true for them. The format was designed to minimize socially desirable
responding.

In at least three studies children's responses to the SDQ-1 and the SPPC have
been compared (Byrne & Schneider, 1988; Marsh, 1990; Marsh & MacDonald-
Holmes, 1990). Across studies, the construct validity of both measures was
verified by confirmatory factor analyses. Marsh and MacDonald-Holmes
(1990) also provide support for the convergent and discriminant validity of
both instruments using multitrait, multimethod analyses and found the scales
to be comparable in terms of internal consistency (coefficient alpha = .82 to
.93 for SDQ-1 subscales, and .81 to .86 for SPPC subscales). With regard to
concurrent validity, significant correlations were found between social self-
concept on the SPPC and peer assessments of sociability/leadership (Byrne
& Schneider, 1988) and between academic self-concept on both the SDQ-1
and the SPPC and teacher evaluations of achievement (Marsh & MacDonald--
Holmes, 1990). Importantly, significant, positive correlations were observed
across the SPPC and SDQ-1 for scores in comparable domains, ranging from
.54 to .86 for Grade 5 to 8 students (Byrne & Schneider, 1988) and from .56
to .68 for Grade 5 students (Marsh & MacDonald-- Holmes, 1990).

These data support previous reports of the psychometric quality of the two
scales and further suggest that, despite format and item variations, these two
measures yield similar estimates of self-concept in specific (comparable)
domains. Study 1 is a replication and extension of these findings regarding
the comparability of the scales in a Canadian sample of fifth and sixth
graders. As in prior studies, the two instruments were compared in terms of
(a) subscale interrelations, (b) internal reliability (Cronbach a), and (c)
correspondence between scores obtained on comparable subscales.
Extending previous research, we examined the stability or test-retest
reliability of subscale scores over a 1-week period, and evaluated the
correspondence of self-reports with teacher and peer assessments in each
domain. Although peer and teacher evaluations are often used as relevant
validity criteria, such comparisons generally have not been conducted across
numerous domains.
Method

Participants. Participants included 217 fifth- and sixth-grade children (107

males, 110 females) from two public schools in southern Ontario, which
serviced predominantly Caucasian middle-class communities. All students
received parental permission for participation in the study.

Procedures. Students participated in two group testing sessions, 1 week

apart, conducted in the classroom setting by female research assistants.
During the first session, students completed subscales of both the SDQ-1 and
the SPPC (order counterbalanced). Students also rated each participating
classmate in terms of four different areas of competence (athletics,
academics, peer relations, and appearance) and in terms of how much they
liked to be with that person at school (sociometric evaluation), with the order
of rating scales counterbalanced. Teachers were also asked to rate
participants in the same four areas of competence. One week later, students
completed either the SPPC or the SDQ-1, with half of the classrooms
randomly assigned to each instrument, providing an evaluation of the
stability of each measure over a brief period.

Materials. Student self-concept was assessed using selected subscales of

the SDQ-1 and SPPC. The five domains that are included in both instruments
were considered: athletic competence, academic competence, peer relations,
appearance, and overall self-worth. For the SPPC, students responded to six
items for each subscale, half of which were worded in a positive direction and
half in a negative direction. For the SDQ-1, students responded to eight
positive and one negative item in each domain, although negatively-worded
items were not included for scoring purposes. The response format for the
SDQ-1 was also simplified, from true, mostly true, sometimes
false/sometimes true, mostly false, false to YES, yes, sometimes, no, NO.
Following procedures recommended by the scale developers, total scores in
each domain were computed as an average of relevant subscale items, with
higher scores reflecting more positive self-concepts.

Others' evaluations of competence were obtained by having teachers and

peers rate each participant on a 5-point scale in each of the four domains.
Because many teachers were uncomfortable rating student appearance, this
evaluation was subsequently dropped. For both academic and athletic
competence ("How well does this person do in schoolwork?" and "How well
does this person do in sports or other outdoor activities?"), response
alternatives ranged from (doesn't do well at all) to 5 (does really weld. Peer
relations ("How well does this person get along with classmates at school?")
were rated from 1 (doesn't get along at all) to 5 (gets along really well). For
the appearance domain ("How good looking or attractive is this person?"),
which was rated by peers but not teachers, responses ranged from 1 (not
good looking at all) to 5 (really good looking). Teacher evaluations reflected
the ratings of a single teacher: peer evaluations were computed as the
average rating received from peers. In both cases, higher scores indicated
greater competence in each domain.
Peer evaluations of liking or popularity were assessed using a rating scale
sociometric measure. Participants rated each classmate in terms of "How
much do you like to be with this person at school?" on a 5-point scale ranging
from 1 (don't like to) to 5 (like to a lot). The average rating received from
peers was computed, with higher scores indicating greater peer acceptance.

Results

Comparisons of the SDQ-1 and the SPPC were made on the basis of (a)
reliability (internal consistency, test-retest stability), (b) subscale
interrelations, and (c) validity (correlations with teacher and peer ratings).
The correspondence of the two instruments was examined through
correlations between scores obtained in comparable domains.

Reliability. Internal consistency (Cronbach a) for each subscale, as presented

in the first two columns of Table 1, was high for both the SDQ-1 and the SPPC.
Stability estimates (test-retest correlations over I week), presented in the last
two columns of Table 1, were also high and comparable across instruments
(all correlations significant at p <.01).

Subscale interrelations. Pearson product moment correlations (onetailed)

were computed to examine the interrelations among the four subscales
within both the SDQ-1 and SPPC. As shown in Table 2, significant but modest
correlations were observed among the four subscales for both instruments.
The only exception to this was the nonsignificant correlation observed
between athletic and academic self-concept on the SDQ-1. These rather low
subscale intercorrelations suggest that the various subscales are tapping
different aspects of the self, although there is some overlap in self-
perceptions across domains. In addition, positive and significant correlations
were observed between domain-specific scores and reported overall self-
worth or self-esteem, suggesting that each domain of self-concept is
related to overall feelings of self-worth. Particularly noteworthy, however, is
the strikingly similar pattern of subscale interrelations observed for the SDQ-
1 and SPPC.

Correspondence with teacher and peer assessments. Pearson product

moment correlations (one-tailed), computed between domain scores and
relevant teacher and peer ratings, are reported in Table 3. Significant
correlations were observed in all cases, and were comparable across the two
instruments. Although significant, the magnitude of these correlations was
moderate to low and varied somewhat across domains. Particularly
noteworthy are the very low correlations observed between self and other
evaluations of peer relations and appearance.

Correlations across self report instruments. Pearson correlations (one-tailed)

were computed between comparable domain scores on the two instruments.
Disattenuated correlations, representing the degree of correspondence
between the two measures once the reliability of each measure is taken into
account, were also computed. As shown in Table 4, the correlations between
comparable subscales were quite high, approaching a ceiling once the
reliability of the measures was taken into account (disattenuated
correlations). Thus, the SDQ-1 and SPPC appear to provide similar, if not
identical, assessments of self-concept, at least for the domains evaluated
here.

Discussion

Data from over 200 fifth- and sixth-grade students revealed an impressive
pattern of consistency across two of the most widely used multidimensional
measures of self-concept. Comparable estimates of internal consistency and
test-retest reliability were obtained, along with highly similar patterns of
correlations across subscales, and across evaluations of self and other. Not
surprisingly, then, self-concept scores in comparable domains were highly
correlated across the two measures. Consistent with prior studies, these data
do not favor one measure over the other, and instead support the conclusion
that the SDQ-1 and SPPC provide comparable and psychometrically similar
assessments of self-concept.

Accordingly, selection of an appropriate self-concept instrument must be

based on considerations other than psychometric quality. For example,
selection may depend on the particular domains of interest. Although both
scales provide for the assessment of self-concept in the areas of academics,
athletics, peer relations, appearance, and general selfworth/esteem, the
SDQ-1 also provides for an assessment of one's relations with parents and for
separate evaluations of competence in math and reading, whereas the SPPC
provides for a self-assessment of one's behavioral conduct at school. Format
differences also may be an important consideration. The SPPC's logical-
alternative format is designed to reduce socially desirable responding, but
our experience suggests that the format is quite confusing for some children.
In addition, the SPPC format implicitly encourages relative comparisons with
others that is characteristic of some, but not all, of the items of the SDQ-1
(e.g., "I can do things as well as most other people" vs. "When I do
something, I do it well"). Finally, there is some variation in item content
across the two measures, with the SDQ-1 including items tapping both
competence and affect, and the SPPC almost exclusively assessing
perceptions of competence (not affect) in an implicit social-comparison
format.

Despite the overall comparability of these two instruments, questions remain

regarding the assessment of self-concept in children. For example, in this
sample, the correspondence between self and other perceptions varied
across domains, with less correspondence observed in the social and
appearance domains. Thus, regardless of the self-concept questionnaire
employed, social self-concept was only weakly related to actual social
status, and self-perceptions of one's appearance were only weakly
associated with peer evaluations of appearance, leading to questions
regarding how children determine their self-perceptions within these
domains. In addition, only well-established self-concept instruments were
compared. How might children's self-evaluations differ if tapped in other
ways, as in the case of open-ended interviews and/or self-ratings?
STUDY 2

In Study 2, our evaluation of the assessment of childhood self-concept was

expanded to consider a wider variety of assessment approaches, based on an
intriguing distinction made by McGuire and McGuire (1987, 1988) between
the "spontaneous" and the "reactive" self. The spontaneous self, as tapped
by open-ended self-descriptions, allows the respondent to determine the
salient features of the self, as a "natural, as-is experience of self" (McGuire &
McGuire, 1987, p. 134). In contrast, the reactive self, as assessed by
experimenter-created questionnaires or ratings, limits the respondent to
consideration of other-derived self-concept domains, and dictates the scope
and focus of one's self-evaluations. With this distinction in mind, we
considered a wider variety of approaches to the assessment of self, while
maintaining our interest in self-concept variations across multiple domains.
Specifically, children's self-assessments in the areas of academics, athletics,
peer relations, and appearance, were assessed by (a) two different types of
self-ratings, (b) verbal self-descriptions derived from open-ended interviews,
and (c) a psychometrically sound, self-report questionnaire tapping
multidimensional aspects of the self (SPPC, Harter, 1982, 1985).

As in Study 1, we were interested in the degree of correspondence observed

among self-assessments derived from various measurement approaches,
and in the degree to which self-assessments reflect the perceptions of
others. If, as symbolic interactionists suggest (see Harter, this issue), the self
emerges as a result of interactions and exchanges with others, children's
self-perceptions should reflect the perceptions of significant others in their
lives. Moreover, as in previous studies (e.g., Byrne & Schneider, 1988; Marsh
& MacDonald-Holmes, 1990, Study 1), others' evaluations are employed often
as an index of convergent validity for self-perceptions. Accordingly, we
compared children's self-assessments across domains with the perceptions
of parents, teachers, and peers, three of the primary significant others in
children's lives at this age.

Finally, the children were asked to describe the "cues" they used to develop
their own self-appraisals, by asking them to explain "how they knew" how
competent they were in each domain. Our focus on children's views of the
"data" used to determine self-assessments constitutes a unique focus within
the literature. Previous efforts have been largely attempts to validate
statistically multidimensional and hierarchical models of the self on the basis
of responses to questionnaires. Although useful, such procedures reveal little
about how individuals (especially children) themselves form their constructs
of self within specific domains.

Method

Participants. The sample was comprised of 161 children (76 females, 85

males) enrolled in Grades 3 to 6 in a single public school in a moderate-sized
city in southern Ontario. The children were predominantly Caucasian and
living in a middle class area. All children had received parental consent for
the study. Parent ratings were obtained for 134 of the 161 students
(approximately 84%).

Procedure. Letters of invitation, including a description of the study and

consent forms, were sent home to parents. On the consent form, parents
were asked to evaluate how satisfied they were with their child's
competencies in each of four domains (academics, athletics, peer relations,
appearance).

The children participated in one group testing session and one individual
interview over a 2-3 week period (order counterbalanced across classrooms),
and were assured of the confidentiality of their responses in both sessions.
During group testing, children completed the SPPC as well as a series of
rating scales on which they evaluated participating classmates and
themselves along several dimensions (described later). Teachers were asked
to complete a similar series of ratings on participating children. During the
interview, children were asked to (a) respond to a series of open-ended
questions about themselves, (b) rate how well they perceived themselves to
perform in each of four domains, and (c) explain how they determined their
own competencies in each domain.

Measures. Self-concept in four domains (athletics, academics, peer

relations, appearance) was assessed using the Self-Perception Profile for
Children (SPPC), as described in Study 1.

Children also completed a series of five peer rating scales, providing peer
assessments of overall liking or popularity (sociometric measure) and of each
participant's competence in each of four domains (schoolwork, athletic
ability, peer relations, appearance), identical to those completed for Study 1.
The sociometric measure was administered first, with the order of the
remaining four scales counterbalanced across classrooms. Children's ratings
of their own competence in each of the four domains (completed along with
peer evaluations) provided an additional index of children's self-perceptions
of competence in each domain, one embedded in a context that likely
enhanced social comparisons.

As in Study 1, classroom teachers were asked to rate each child's

competence in each of four domains using the same 5-point rating scales.
Two teachers were reluctant to evaluate children's appearance, reducing the
sample size for some analyses. Again, higher scores were indicative of more
positive ratings in each domain.

Spontaneous self-descriptions were obtained during individual interviews

when children were asked a series of open-ended questions about the self.
The questions were worded such that particular domains or aspects of the
self were not highlighted, permitting children to emphasize various aspects
of their lives as they deemed appropriate. Effort was made, however, to elicit
both positive and negative self-descriptions. Specific interview questions,
adapted from a self-report interview developed by Damon and Hart (1982),
were:
1 .Tell me about yourself. What are you like? What kind of a person are you?

2. Tell me some things about yourself that you think are good.

3. Tell me some things about yourself that you think are not so good.

4. What are you especially proud of about yourself?

5. Tell me the things about yourself that you are not really proud of.

6. What are the things that you do best?

7. What are the things that you do the worst?

Responses were audio-recorded and later transcribed. For coding purposes,

responses were first separated into distinct idea units by independent coders
(two of the authors, interrater reliability = 92%). Each response unit was then
categorized by independent coders (the authors) in terms of domain
addressed (academic, peer, athletic, and appearance domains and "other"),
as well as valence (positive, neutral, or negative). Discrepancies were
resolved through discussion and/or the decision of a third coder. Interrater
reliability for these judgments was high, for both domain (overall, 96%,
academic, 96%, athletic, 98%, peer, 95%, appearance, 90%) and valence
codes (overall, 97.5%, positive 98%, neutral, 88%, negative, 98%). From
these coded responses two indices were computed: (a) percentage of self-
statements within a domain over all self-statements made (% domain
statements), reflecting the degree to which the child emphasized a given
domain over other domains, and (b) percentage of positive self-statements
made within a domain over all domain statements (% positive statements),
reflecting the degree to which self-statements in a given domain were
positive or self-enhancing.

Next, children rated on a 10-point response wheel how well they perceived
themselves to perform in each domain. Response wheels were made from
two circles of interlocking cardboard, each a different color. On the face of
each circle were lines that create 10 equal "pie slices" and the interlocking
circles could be rotated to reveal any number of "slices" of either color. Each
colored circle was labeled with either a positive or negative self-description
for a particular domain (e.g., "I get along really well with other kids" and "I
don't get along well at all with other kids" for the peer relations domain; "I do
really well in my schoolwork" and "I don't do well at all in my schoolwork" for
the academic domain). These response wheels, easily understood by the
children, corresponded to 10-point rating scales, allowing for greater
response variability, with higher scores indicating more positive self-
perceptions. They differed from other self-ratings in that (a) they provided a
visual representation of one's self-assessments that may have been more
meaningful for some students and (b) they did not highlight social
comparison (as did self-ratings embedded in the peer evaluations). The
response wheels provided a final set of self-evaluations, completed on a
different day.
Finally, children were asked "how they could tell" if they were doing well or
not doing well in each domain, in an attempt to identify the sources of
information the children used to evaluate their performance in each domain.
Responses were recorded verbatim and later categorized in terms of the type
of "cues" used to determine their self-assessments. Six major types of cues
were described by the participants, although many of the categories only
occurred in particular domains: objective outcomes (grades, test scores,
goals, wins/losses, etc.); direct feedback from others ("__ tells me I am
good"); direct affect or liking (e.g., "They tell me that they like me");
friendship (e.g., "because I have friends"); self-observations (interpretations
of one's own behavior); and performance inferred from the behavior of others
(evaluations of self based on how one is treated by others). The latter two
categories were further divided into several subcategories. Specifically, self-
observations included (a) general self-observations (e.g., "I look at myself in
the mirror," "When I get all dressed up"); (b) self-descriptions of
psychological states (e.g., "I feel good/pretty"); (c) work-related behavior
(references to completion of work, speed of performance, neatness, etc.); (d)
ability/inability to perform tasks (e.g., "I could do it perfectly the first time I
tried"); (e) interpretations of one's own performance (references to ready
understanding, task ease/difficulty, enjoyment, etc.). Performance inferred
from the behavior of others included the subcategories of (a) general
statements (e.g., "The way teachers/coaches treat you"); (b) positive social
behaviors or absence of negative behaviors (e.g., "They invite me to parties,"
"They don't tease me," or "They choose me as captain"); (c) negative social
behaviors or absence of positive behaviors (e.g., "They never include me
when they play"); (d) shared or mutual affect/cooperation (e.g., "We laugh a
lot when we get together," "We have fun together"); (e) communication (e.g.,
"We talk to each other"); (f) intimacy/loyalty/acceptance (e.g., "I can tell my
friends anything," "I can trust her not to tell secrets"); (g) similarity/ shared
values (e.g., "We like the same things"). Unclassifiable and "don't know"
responses were coded separately (see Table 8 for a list of categories).
Interrater reliability, obtained for a random sample of 25% of the children,
was computed across categories and was consistently high across domains
(agreement = 89% for academics; 90%, peer relations; 91%, athletics; and
95%, appearance).

Parents of participating children were asked to rate on a 5-point scale ranging

from 1 (very happy to 5 (not at all happy how satisfied they were with their
child's performance in each of the four domains (schoolwork, getting along
with peers, physical activities or sports, and appearance).

Results and Discussion

First examined were the correlations among the various self-perceptions

within each domain. As shown in Table 5, the correspondence between
different types of self-assessments varied considerably as a function of the
domain tapped. The greatest coherence among self-perception measures
was found in the athletic domain in which correlations of .6 were obtained for
the Harter scale and both self-ratings. The two self-rating measures,
although administered on different days, also were strongly correlated (.56),
which could reflect the stability of self-ratings over a 2- to 3-week period.
Questionnaire and rating assessments of athletic competence also showed
significant associations with self-descriptions spontaneously offered in an
interview, with correlations ranging from .21 to .40. Thus, children who
described themselves as athletically competent on the SPPC also rated
themselves positively in athletic ability on two separate occasions using
different formats, emphasized the athletic domain in their interviews, and
described themselves positively in terms of athletics and other physical
activities. This degree of coherence among measures was not observed in the
other domains.

in the academic and appearance domains, there was somewhat less

correspondence among self-perceptions as assessed by various methods.
Self-report questionnaire and self-ratings, for example, correlated from .45
to .59 in the academic domain and from .39 to .45 in the appearance domain.
In both of these domains, however, there was little, if any, correspondence
between self-ratings/questionnaires and spontaneous self-descriptions
(interview data), with correlations in the .1 to .2 range.

Most surprising were results obtained in the peer relations domain. There was
little correspondence among self-report questionnaire and selfratings and no
relationship between interview measures and self-assessments derived from
questionnaires or rating scales (see Table 5).

It is interesting to compare these findings with those of Study 1. In Study 1,

comparing two multi-item, self-report questionnaires with wellestablished
psychometric properties, minimal variation was observed across domains,
and relations between comparable subscales were consistently high. In
contrast, the results of Study 2 suggest that the correspondence among
different types of self-assessments varies as a function of the domain
considered, especially when single-item and nonstandardized measures are
used, and hence one cannot assume correspondence across measures in all
domains. Subsequent analyses considered factors that might contribute to
this interdomain variation.

First considered was the convergent validity of children's self-perceptions as

a function of domain. Specifically, we examined the relations between self-
assessments and the evaluations of teachers, peers, and parents within each
of the four domains. As shown in Table 6, the greatest correspondence
between self- and other-evaluations was obtained in the academic and
athletic domains, where self-assessments were significantly correlated with
teacher, parent, and peer evaluations, with a few exceptions. Specifically, in
the athletic domain, teacher and peer, but not parent, ratings were
significantly related to children's spontaneous self-descriptions. In the
academic domain, teacher, parent, and peer evaluations were not
significantly related to the degree to which children generally emphasized
academics in their self-descriptions (% domain statements).

In clear contrast, relations between self- and other evaluations were virtually
nonexistent in the domains of peer relations and, especially, appearance. In
the social domain, the correlations between self and peer or teacher
evaluations were sometimes significant but very small in magnitude, and
almost nonexistent when parent evaluations or spontaneous self-descriptions
were considered. In the appearance domain, there were no significant
relations obtained between self- and other assessments, suggesting perhaps
that beauty is indeed in the eye of the beholder.

These results are highly similar to those reported by Marsh and his colleagues
(Marsh, 1988; Marsh & Craven, 1991). Across eight studies in which the SDQ-
1 was used to assess children's self-perceptions and a single-item rating
scale was used to assess teacher perceptions of these children, Marsh (1988)
found average self-other agreement correlations for academic, athletic, peer,
and appearance domains to be .37, .38, .29, and .16, respectively. Marsh and
Craven (1991) evaluated agreement between children's SDQ-1 subscale
scores and perceptions of teachers, mothers, and fathers. Self-other
correlations tended to be somewhat higher than those reported in Marsh
(1988) but the pattern of results was similar, with the highest agreement
observed in the academic and athletic domains and somewhat weaker
agreement observed in the peer domain. The consistency of our results with
those of previous studies supports the robustness of this differential pattern
of self-other agreement across domains.

If self-perceptions are derived to a large extent from feedback from

significant others, as symbolic interactionists suggest, it seems important to
determine whether the feedback obtained from others is more or less
consistent across domains. Accordingly, we examined the correlations among
teacher, peer, and parent evaluations within each domain. The results,
presented in Table 7, indicated that others' evaluations of a child's
performance or competence were, with few exceptions, significantly
correlated across domains. Marsh and Craven (1991) also found few
differences among the perceptions of teachers, mothers, and fathers in any
domain. Although the magnitude of the correlations was somewhat larger in
the athletic and academic domains than in the social (peer) and, especially,
appearance domains, the discrepancies were not sufficiently large to suggest
that a child's performance in the latter two domains was perceived in a less
cohesive or consistent manner by significant others in the child's life. It is
important to note, however, that others' evaluations were least consistent in
the appearance domain, a point to which we will return shortly.

Another possibility, not unrelated to the issue of consistency of feedback,

comes from an argument by Bohrnstedt and Felson (1983) that the feedback
one receives about performance in some domains may be more ambiguous
or less verifiable than the feedback one receives in other domains. In
particular, they suggested that feedback in the social domain is more
ambiguous than in the academic or athletic domains. In an attempt to
address this issue, we examined the cues or sources of information which the
children claimed to utilize in evaluating their own competence across
domains. These cues were derived from children's responses to the question
"How can you tell?" if you're doing well or not doing well in each domain. The
proportion of children who mentioned each of the 18 different types of cues
across domains is presented in Table 8.

In both the academic and athletic domains, children most often relied on
rather direct sources of information, such as that obtained from academic or
athletic outcomes including references to goals, scores, winning, losing, etc.,
in the athletic domain (mentioned by 55% of the children) and references to
grades, test scores, marks, etc., in the academic domain (mentioned by 82%
of the children). In addition, a substantial number of children relied on direct
feedback from others, with 42% and 33% of the children mentioning this
source of information in the athletic and academic domains, respectively. It is
important to recall here that in these two domains in particular, direct
feedback from others is likely to be a consistent source of information, given
our earlier findings of a rather high correspondence across teachers, parents,
and peers with regard to children's performance in these two domains.

Another frequently mentioned source of information was self-observations of

own performance. In the academic domain, self-observations included such
things as completing work, speed of performance, neatness, etc. under the
category "work-related behavior," or effort expended, ease of understanding,
task difficulty, and enjoyment under the category "interpretations of own
performance." In the athletic domain, self-observations included self-
perceptions of the ability or inability to perform a task and, under the
category "interpretations of own performance," references to effort, speed of
acquisition, enjoyment, etc. These self-observation categories were
mentioned by a little over a third of the children. In the academic and athletic
domains, few children reported reliance on more indirect cues such as
inferring their performance from the behavior of others or such things as
special privileges offered, tutoring others, being chosen leader, etc.

In the appearance domain, the majority of children (nearly 60%) mentioned

self-observation as a major cue, including such responses as "I look in the
mirror," or "When I'm all clean and neat and my hair is combed," etc. Another
source of information for over half of the children (55%) was direct feedback
from others, most notably parents and peers. Although others' feedback
seems to be a primary source of information regarding appearance, the
feedback received from others in the appearance domain may be somewhat
unique, given earlier findings that the appearance domain demonstrated the
least consistency across parent, peer, and teacher evaluations, and that self-
assessments of appearance were totally unrelated to others' evaluations of
appearance. Moreover, almost one third of the children relied on more
indirect cues in evaluating their appearance, particularly inferences derived
from the behavior of others, including such things as having friends, having a
boyfriend or girlfriend, being whistled at, etc. In the appearance domain,
then, most children relied on their own judgments of their appearance and/or
on direct (as well as indirect) feedback from others, which according to
previous findings may have been inconsistent and ultimately unrelated to
self-evaluations.
Finally, in the social domain, where our previous data indicated considerably
less correspondence among self-assessments and between self and other
evaluations, we found that children relied almost exclusively on less direct
and more inferential sources of information. Specifically, 83% and 90% of the
children in this sample mentioned positive and negative social behavior by
others as a primary cue in the social domain, including such things as
fighting, sharing, helping, being ignored, etc. A few children also relied on
even more indirect cues such as shared affect, intimacy and loyalty,
similarity, etc., as sources of information about how well they were getting
along with others. More direct sources of information in the form of direct
feedback from others or direct affect or liking were seldom mentioned. In the
case of the peer domain, then, the cues utilized to evaluate competence are
more indirect and inferential than those cited in other domains. This may
account, in part, for the lack of correspondence observed across social self-
perceptions. As Bohrnstedt and Felson (1983) suggested, feedback in the
social domain may be indeed more ambiguous and less verifiable than in
other domains.

SUMMARY AND CONCLUSIONS

In summary, the results of the present study suggest that the measurement
of the self remains a difficult task even when the focus is on domain-specific
assessment rather than a global or unitary construct of self. As we have
demonstrated, the correspondence among different self-perception
measures varies considerably as a function of the domain being tapped, with
a reasonable degree of coherence across self-measures observed in the
athletic domain but virtually no relationship across self-measures in the
social domain.

Further, the present results indicated that the correspondence between self
and others' perceptions also varied across domains, with significant
correlations observed between self and other assessments in the athletic and
academic domains, but little or no correlation between self and other
perceptions observed in the social and appearance domains. This pattern of
differential correspondence across domains is not readily attributable to
variations in the consistency of others' perceptions of one's competence
within domains, although the correlations obtained among others'
perceptions were slightly higher in the athletic and academic domains than in
the appearance and social domains.

The interdomain variation observed in the present study, however, may be in

part a function of the ambiguity of feedback utilized by children across
domains. in the athletic and academic domains, children relied on direct
sources of information such as academic or athletic outcomes as well as self-
observations in judging their own competence. In contrast, in the social
domain, most children relied on less direct, more inferential sources of
information, particularly those from social interactions with others, which are
often quite ambiguous and open to multiple interpretations. In the
appearance domain, most children relied on self-observations and direct
feedback from others, although our earlier data suggested little
correspondence between self and other assessments in the appearance
domain. Replication of these findings with other samples is needed, and
future research may benefit from examination of whether the pattern of
results obtained in the present study is evident across samples differing in
terms of various characteristics (e.g., age, sex, SES, ethnic or racial
composition, etc.).

In conclusion, the results of the present study suggest that the recent shift
within the self literature from more general to domain-specific
selfassessments has led to the finding that children may process information
about the self quite differently across domains. Thinking of these domains as
parallel has been primarily a matter of convenience in previous research, but
on closer inspection such an assumption breaks down. In the present study,
for example, we have demonstrated that the consistency of self-
assessments, the correspondence between self and other evaluations, and to
some extent the consistency of others' evaluation varies considerably across
domains, as do the sources of information children utilize as feedback
concerning their own performance or competence. It would be beneficial to
consider in the future the unique ways in which children process information
regarding themselves as a function of the domain assessed and the
implications of such processing differences for subsequent behavior, as well
as self-evaluation.

[Reference]

REFERENCES

[Reference]

BOHRNSTEDT, G. W., & FELSON, R. B. (1983). Explaining the relations among

children's actual and perceived performances and self-esteem: A companion
of several causal models. Journal of Personality and Social Psychology, 45, 43-
56.

BYRNE, B. M. (1996). Measuring self concept across the life span: Issues and
instrumentation. Washington, DC: American Psychological Association.
BYRNE, B. M., & SCHNEIDER, B. H. (1988). Perceived competence scale for

children: Testing for factorial validity and invariance across age and ability.
Applied Measurement in Education, 1, 171-187.

DAMON, W., & HART, D. (1982). The development of self-understanding from

infancy through adolescence. Child Development, 53, 841-864.

HARTER, S. (1982). The perceived competence scale for children. Child

Development, 53, 87-97.

HARTER, S. (1983). Developmental perspectives on the self-system. In P. H.

Mussen (Series Ed.), & E. M. Hetherington (Vol. Ed.), Handbook of child
psychology: Vol. 4. Socialization and personality development (4th ed.). New
York: Wiley.
HARTER, S. (1985). Manual for the Self Perception Profile for Children.
University of Denver.

LEAHY, R. L. (1985). The development of self. New York: Academic.

MARSH, H. W. (1988). The Self Description Questionnaire (SDQ-1): A theoreti

[Reference]

cal and empirical basis for the measurement of multiple dimensions of

preadolescent self concept: A test manual and research monograph. San
Antonio, TX: Psychological Corporation.

MARSH, H. W. (1990). Confirmatory factor analysis of multitrait-multimethod

data: The construct validation of multidimensional self-concept responses.
Journal of Personality, 58, 661-692.

MARSH, H. W., & CRAVEN, R. (1991 ). Self-other agreement on dimensions of

preadolescent self-concepts: Inferences by teachers, mothers, and fathers.
Journal of Educational Psychology, 83, 393-404.

MARSH, H. W., & MACDONALD-HOLMES, I. W. (1990). Multidimensional

selfconcepts: Construct validation of responses by children. American
Educational Research Journal, 27, 89-117.

MARSH, H. W., SMITH, I. E., & BARNES, ). (1983). Multitrait, multimethod

analyses of the Self-Description Questionnaire: Student-teacher agreement
on multidimensional ratings of student self-concept. American Educational
Research Journal, 20, 333-357.

McGUIRE, W. J., & MCGUIRE, C. V. (1987). Developmental trends and gender

differences in the subjective experience of self. In T. Honess & K. Yardley
(Eds.), Self and identity. New York: Routledge & Kegan-Paul.

MCGUIRE, W. )., & MCGUIRE, C. V. (1988). Content and process in the

experience of self. Advances in Experimental Social Psychology, 21, 97-144.

SHAVELSON, R. )., HUBNER, ). )., & STANTON, G. C. (1976). Self-concept:

Validation of construct interpretations. Review of Educational Research, 46,

407-441.

SULS, )., & GREENWALD, A. (1985). Psychological perspectives on the self

(Vol. 3). Hillsdale, NJ: Erlbaum.

WYLIE, R. C. (1961 ). The self concept. Lincoln: University of Nebraska Press.

WYLIE, R. C. (1974). The self concept: A review of methodological

considerations and measuring instruments (Vol. 1). Lincoln: University of
Nebraska Press.
WYLIE, R. C. (1979). The self concept (Vol. 2). Lincoln: University of
Nebraska Press.

WYLIE, R. C. (1989). Measures of self concept. Lincoln: University of

Nebraska Press.

[Author Affiliation]

Shelley Hymel, Department of Educational and Counseling Psychology and

Special Education; Lucy LeMare, Faculty of Education; Erik Z. Woody,
Department of Psychology; Elise Ditner, Peel Board of Education, Mississauga,
ON.

This research was supported by grants from the University of Waterloo and
the Social Sciences and Humanities Research Council of Canada. Portions of
this paper were presented at the University of Waterloo Conference on Child
Development, Waterloo, ON, May 1988. Some of the data were collected as
part of an unpublished undergraduate honors thesis by Vanessa Ploc, and as
a pilot study for an unpublished doctoral thesis by Dr. Annie Steinhauer. We
thank the participating staff, parents and students at Alpine, Crestview, and
Southridge public schools in Kitchener-Waterloo, ON, for their cooperation in
this research, and Vanessa Ploc and Annie Steinhauer for their assistance in
data collection.

Correspondence may be sent to Shelley Hymel, Department of Educational

and Counseling Psychology and Special Education, Faculty of Education,
University of British Columbia, 2125 Main Mall, Vancouver, BC, V6T 1Z4,
Canada. Electronic mail may be sent via Internet to shelley.hymel@ubc.ca.

Merrill-Palmer Quarterly, October 1999, Vol. 45, No. 4, pp. 602-623. Copyright
1999 by Wayne State University Press, Detroit, MI 48201

Copyright Wayne State University Press Oct 1999. Provided by ProQuest LLC. For permission to reuse this
article, contact Copyright Clearance Center.

Self-concept and self-esteem: a clarification of

terms.
From:
Journal of School Health
Date:
February 1, 1997
Author:
King, Keith A.
More results for:
self esteem AND rebt OR self concept
 http://www.highbeam.com/doc/1G1-19191024.html
Health educators play a part in helping young people to develop self-esteem
and healthy behavior. Their first order of business should be defining self-
concept and self-esteem. There is much confusion regarding each term's
appropriate use. Specific definitions are necessary for researchers to provide
a good knowledge base for educators to work from. Future research should
focus on definitions of self-concept and self-esteem and their effect on
healthy behavior.

How children feel about themselves represents a crucial component in child

growth and development. Since children spend most of their growing years in
classrooms, research pertaining to children's self-concept and self-esteem
often has been conducted in these settings. Several studies found children's
self-concept and self-esteem associated with academic achievement,
performance in sports, involvement in substance use, teen-age pregnancy,
quality of peer interactions, and adoption of specific coping skills.[1-3]

Thus, the health education discipline historically has recognized the

importance of self-concept and self-esteem in the adoption of healthy
behavior by youth. Studies of self-concept and self-esteem, in turn,
confirm the direct influence of these factors in health education.[4] Therefore,
examining these factors should assist in designing future health education
programs for today's schoolchildren.[1]

To understand the relationships between self-concept, self-esteem, and

healthy behavior, a clear delineation between self-concept and self-
esteem should be maintained. This commentary reviews literature
examining the importance of self-concept/self-esteem issues pertaining to
adoption of healthy behavior and examines relevant definitions of self-
concept/self-esteem offered in the health education discipline.

SELF-CONCEPT, SELF-ESTEEM AND HEALTHY BEHAVIORS

Health educators face the formidable task of assisting children and

adolescents in the process of healthy growth and development. With the
physical and intellectual growth of youth, personal and social growth must be
nurtured as well.[5] Perceptions children and adolescents hold of themselves
form the core of these dimensions.[5] Based on this framework, studies have
examined the effects of self-concept and self-esteem on health behavior.
For example, children with realistic self-concepts and higher levels of self-
esteem engage in fewer negative health behaviors and express less
intention to do so in the future.[6, 7]

Miller,[8] in a study about the development of self-esteem on attitudes

related to alcohol in elementary-grade school-children, found that positive
self-esteem decreased the likelihood for children to engage in alcohol and
drug use. Similarly, other studies examining the relationship between self-
concept, self-esteem, and substance use found home self-esteem (one's
self-evaluation within the context of the home), school self-esteem (one's
self-evaluation within the context of the school), and overall self-concept
related inversely to alcohol, tobacco, other drug use, and future intention to
use.[2, 9, 10]

Torres, Fernandez, and Maceira' found self-esteem associated positively with

personal, mental, and social health in young adolescents ages 12-13, and
with mental health and safety aspects in older adolescents ages 15-16. These
findings underscore the role positive self-esteem can play for individuals
during the critical period of adolescence when physical and mental changes
affect self-concept.

With regard to sexual behavior, youth with low self-esteem are more likely
to become involved in premarital sexual relationships and teen-age
pregnancies. In turn, it has been argued that individuals with low self-
concept/self-esteem tend to be more susceptible to social influences than
those with higher self-concept/self-esteem.[12] Thus, as Hayes and
Fors[13] assert, low self-esteem could become a precipitating factor for
adoption of unhealthy behavior. By making a fervent effort to enhance
positive and realistic child self-concept/self-esteem in classrooms, health
educators may increase the likelihood that healthy behavior will be adopted
by these children. Therefore, health educators should understand the discrete
definitions of self-concept and self-esteem.

DELINEATING SELF-CONCEPT AND SELF-ESTEEM

The literature offers several definitions for the terms, self-concept and self-
esteem. Some writers assert that self-esteem reflects the difference
between the ideal self (how one would like to be) and the actual self (how
one actually iS).[14, 15] Atherley[16] suggested that an individual with
substantial distance between the actual self and ideal self will develop a
negative perception of self (low self-esteem), while an individual with
modest distance between the actual self and ideal self will develop a more
positive perception of self (high self-esteem).

Coopersmith[17] defined self-esteem as "the evaluation which the individual

makes and customarily maintains with regards to him/herself."[15] The
California Task Force to Promote Self-Esteem and Personal and Social
Responsibility,[18] extended this definition to include "appreciating my own
worth and importance" and "having the character to be accountable for
myself and to act responsibly towards others."

However, Brooks[14] observed that definitions focusing solely on how

individuals think and feel about themselves may cause misunderstanding
between self-concept, self-esteem, self-centeredness, conceit, and
selfishness. Likewise, Wells and Marwell[19] identified several terms often
associated with self-concept/self-esteem which may lead to further
confusion. These terms included self-love, self-confidence, self-acceptance,
self-satisfaction, self-evaluation, self-appraisal, self-worth, self-ideal, sense
of adequacy, personal efficacy, sense of competence, congruence, ego, and
ego-strength.
To add to the confusion, the terms self-concept and self-esteem often are
used interchangeably. Yet, Beane and Lipka[5] argued that self-concept and
self-esteem clearly represent two discrete dimensions. They defined self-
concept as "the perception(s) one has of oneself in terms of personal
attributes and the various roles which are played or fulfilled by the
individual." They further noted that self-concept represents the "description
an individual attaches to himself or herself... in terms of roles and attributes."
Since self-concept represents "only a description of the perceived self and
does not involve a value judgment," self-concept should not be depicted as
positive or negative. Conversely, self-esteem refers to the "evaluation one
makes of the self-concept description and, more specifically, to the degree
to which one is satisfied or dissatisfied with it, in whole or in part." For
example, individuals describing themselves as tall may feel happy or
unhappy about being tall. Self-concept would refer to the perception of
being tall, whereas self-esteem would refer to one's feelings about being tall
(happy versus unhappy). Thus, contrary to the definition of self-concept, it
is acceptable to consider self-esteem as being positive, negative, or
neutral.[5]

Despite these distinctions, much confusion remains concerning appropriate

use of each term. Arguments thus have been made which focus not only on
the variability and inconsistency of the definitions of self-concept and self-
esteem, but on the measurement of self-esteem and self-concept in
research studies.[2,15] The importance of clarity between the terms becomes
evident when one considers possible effects of the confusion on researchers
and educators. Researchers inadvertently may omit important issues or
explanations due to acceptance of a specific definition or scale, thus
providing a vague knowledge base from which educators obtain information.
To assist in clarifying the confusion, some scales commonly used to measure
self-concept (Table 1) and self-esteem (Table 2) are displayed. For more
information on the descriptive and psychometric characteristics of these
scales, see Bracken and Mills' comprehensive review of self-concept/self-
esteem scales.[20]

Table 1 Self-Concept Scales of Measurement Used in Health Education

Survey Instrument Subscales of Self-Concept

(Year Developed) Assessed (Number of Items)

Multidimensional Self-Concept Social, competence, affect,

Scale (1992) academic, family, physical,

total self (150)

Piers-Harris Self-Concept Scale Behavior, intellectual,

"The Way I Feel About Myself" school, physical

Scale (1984) appearance/attributes,

anxiety popularity

satisfaction (80)

Pyrt-Mendaglio Self-PerceptionAcademic, athletic, social,

Scale (1992) evaluative (24)

Self-Description Questionnaire I Physical abilities/

(1988)appearance, peer/parent

relations, reading, math,

general school, general

self (76)

Self-Description Questionnaire II Physical abilities/

(1990)appearance, opposite

sex/same sex/parent

relations, honesty/

trushworthiness, emotional

stability, math, verbal,

general school, general

self (102)

Self-Perception Profile for Scholastic competence,

Children (1988) social/athletic acceptance,

physical appearance,
 behavioral conduct, global

self-worth (36)

Tennessee Self-Concept Scale (1988) Identity, satisfaction,

(1988)behavior, physical, mortal/

ethical, personal, family,

social (100)

Table 2

Self-Esteem

Scales of Measurement Used in Health Education

Survey Instrument Type of Self-Esteem Assessed

(Year Developed) (Number of Items)

Coopersmith Self-Esteem Inventories General self, social self/

(1987)peers, home/parents, school/

academic (58)

Culture-Free Self-Esteem General, social/peers

Inventories, 2nd ed.(1992)related, academic/school

related, parents/home related

(Form A = 60, Form B = 30,

Form AD = 40)

Gordon Personal Profile Ascendency, responsibility,

(1978)emotional stability,
 sociability

Hare Self-Esteem ScalePeer, school, home

(1977)(30)

Robson Self-Esteem Questionnaire Contentment, self-acceptance,

(1988)self-worth/significance/

attractiveness/competence/

ability to satisfy

aspirations (30)

Rosenberg Self-Esteem Scale Global self

(1965)(10)

Self-Esteem Index Familial acceptance,

(1991)academic competence, peer

popularity, personal

security (80)

RECOMMENDATIONS FOR HEALTH EDUCATORS

Recommendations aimed at furthering the understanding about the effects of

self-concept and self-esteem as they pertain to adoption of healthy
behaviors by children are provided below.

1) Future research should focus on development of specific definitions

pertaining to self-concept and self-esteem as a means to consistently
differentiate the two terms, thereby increasing validity and reliability.

2) Health educators should introduce these specific definitions to elementary

and secondary teachers to help them with their understandings and
implementations of each.
3) Future research should examine the effects of self-concept and self-
esteem on healthy behavior, using these specific and consistent definitions.

4) Future research should examine the effects of different levels of self-

concept and self-esteem on adoption of healthy behavior, and share the
results with teachers.

5) Future research should further evaluate teaching methodologies, as well as

the effect of a positive school environment, to better understand the impact
of direct and indirect teaching pertaining to the enhancement of self-
concept/self-esteem.

CONCLUSION

Self-concept and self-esteem play important roles in children's decisions to

engage in healthy behavior. Therefore, enhancement of self-concept and
self-esteem in schools is encouraged. Similarly, a clear and specific
delineation between the two terms should be underscored by health
educators. Future research in the area should focus on advocating efforts
which promotes self-concept/self-esteem while maintaining clear and
consistent definitions.

References

[1.] Torres R, Fernandez F, Maceira D. Self-esteem and value of health as

correlates of adolescent health behavior. Adolescence. 1995;30(118):403-
412.

[2.] Emery EM, McDermott RI, Holcomb DR, Marty PJ. The relationship
between youth substance use and area-specific self-esteem. J Sch Health.
1993;63(5):224-228.

[3.] Branden N. How To Raise Your Self-Esteem. New York, NY: Bantam; 1987.

[4.] Giblin PT, Poland ML, Ager PD. Clinical applications of self-esteem and
locus of control to adolescent health. J Adol Health Care. 1988;9:1-14.

[5.] Beane JA, Lipka RP. Self-Concept, Self-Esteem and the Curriculum.
Newton, Mass: Allyn and Bacon, Inc; 1984.

[6.] Dielman T, Leech S, Larenger A, Horvath W. Health locus of control and

self-esteem as related to adolescent behavior and intentions. Adolescence.
1984;19(76):935-950.

[7.] Petersen-Martin J, Cottrell RR. Self-concept, values, and health behavior.

Health Educ. 1987;18(5):6-9.

[8.] Miller RL. Positive self-esteem and alcohol/drug related attitudes among
school children. J Alc Drug Educ. 1988;33(3):26-31.
[9.] Young MI, Werch CE, Bakema D. Area specific self-esteem scales and
substance use among elementary and middle school children. J Sch Health.
1989;59(6):251-254.

[10.] Bonaguro E, Bonaguro J. Self-concept, stress symptomatology, and

tobacco use. J Sch Health. 1987;57(2):56-58.

[11.] Miller BC, Christensen RB, Olsen TD. Adolescent self-esteem in relation
to sexual altitudes end behavior. Youth & Soc. 1987;19(1):93-111.

[12.] Bandura A. Principles of Behavior Modification. New York, NY: Holt,

Rhinehart, and Winston; 1969.

[13.] Hays DM, Fors SW. Self-esteem and health instruction: Challenges for
curriculum development. J Sch Health. 1990;60(5):208-211.

[14.] Brooks RB. Self-esteem during the school years: Its normal
development and hazardous decline. Pediatr Clin North Am. 1992;39:517-
550.

[15.] Lawrence D. Enhancing Self-Esteem in the Classroom. London,

England: Paul Chapman; 1988.

[16.] Atherley CA. The effects of academic achievement and socioeconomic

status upon self-concept in the middle years of school: A case study. Educ
Res. 1990;32:224-229.

[17.] Coopersmith S. The Antecedents of Self-Esteem. San Francisco, Calif:

WH Freeman; 1967.

[18.] California Dept of Education. Toward a State of Esteem: The Final

Report of the Task Force to Promote Self-Esteem and Personal and Social
Responsibility. Sacramento, Calif: California Dept of Education. 1990.

[19.] Wells LE, Marwell G. Self-Esteem: Its Conceptualization and

Measurement. Beverley Hills, Calif Sage Publications; 1976.

[20.] Bracken BA, Mills BC. School counselors' assessment of self-concept: A

comprehensive review of 10 instruments. The Sch Counselor. 1994;42:14-31.

Keith A. King, MS&ED, Graduate Assistant, Dept. of Health Promotion and

Human Performance, The University of Toledo, 2801 W. Bancroft St., Toledo,
Ohio 43606. This article was submitted August 5, 1996, and revised and
accepted for publication December 23, 1996.

COPYRIGHT 1997 American School Health Association. This material is published under license from the
publisher through the Gale Group, Farmington Hills, Michigan. All inquiries regarding rights should be
directed to the Gale Group. For permission to reuse this article, contact Copyright Clearance Center.
Rational-Emotive-Behavior Therapy: A Training
Manual
From:
Journal of Cognitive Psychotherapy
Date:
January 1, 2000
Author:
Dowd, E Thomas
More results for:
REBT

http://www.highbeam.com/doc/1P3-
1474560991.html
Rational-Emotive-Behavior Therapy: A Training Manual Windy Dryden. New
York: Springer Publishing (www.springerpub.com). 1999, 292 pp., $42.95
(hardcover).

Other than The Great Albert himself, I know of no one as prolific in writing
about Rational-Emotive-Behavior Therapy (REBT) as Windy Dryden. His
output has been truly prodigious and, in the main, quite informative.

His latest book is a prime example. What Dr. Dryden has done is to write a
book that attempts to recreate the atmosphere of the many training sessions
he has conducted around the world over the years. It's an ambitious project
but is largely achieved. His attention to detail in those workshops must be
incredible because this is one of the best organized and detailed books I have
ever read.

The book consists of 22 modules, each in turn consisting of one or up to 18

units (for a total of 103 units). There is not space enough in this review to
mention all the modules and certainly not all the units but I'll give several as
examples. Modules 1 and 2 consist of the theory and practice, respectively, of
REBT. Module 8 consists of methods for assessing A (the Activating Event)
while Module 12 is on Goal-Setting. Other modules include Didactic Disputing
of Irrational Beliefs, Negotiating Homework Assignments, and Examples of
Albert Ellis's Disputing Work. Units within Module 13 (Eliciting Commitment to
Change) include The Cost-Benefit Analysis Form (52), Using Socratic
Questions (53), and Reconsidering the Cost-Benefit Analysis (55).

The theory aspects are familiar to anyone who has read Albert Ellis's writings
over the years. They include taking responsibility for your own disturbance
and the central place of disputing irrational thoughts in the practice of REBT.
But there are some different nuances. The number of irrational ideas seem
now to have been reduced to four (from the original 12 or 13): Musts,
Awfulizing, Low frustration tolerance, and Self/other downing. Furthermore,
there are three arguments (or methods of disputation) that Dryden uses.
These are: Empirical arguments (looking for empirical evidence that confirms
or disconfirms the client's irrational beliefs), Logical arguments (examining
whether or not the client's beliefs, are logical), and Pragmatic arguments (do
the irrational beliefs get clients what they want). Furthermore, as an example
of the tight and detailed logic of this book, Dryden recommends that the
therapist use one type of argument consistently before shifting to another,
rather than constantly shifting. It is this extreme attention to detail that
makes this book especially noteworthy.

Throughout the book there are numerous typescripts of therapist-client

dialogues; indeed, some units consist of little else. These make the principles
and practice come alive, although I always had the feeling that clients usually
don't see therapists' points quite so easily and readily as they do here. There
are also many analogical examples that a therapist might use to help clients
see the irrationality of their ways, such as "The Four Surgeon Example", "The
Blind Man Example", and "The Take a Wild Guess" method. These examples
document Dryden's creativity as well as encourage the reader to
demonstrate his or her own creativity. There are even three appendices; a
homework skills monitoring form, possible reasons for not doing self-help
assignments, and a place (the RET Institute, naturally!) to obtain further
training.

Many of the units go beyond REBT and discuss and illustrate methods and
techniques that are common to all forms of psychotherapy. These include The
Core Conditions (Unit 5) and Therapeutic Style (Unit 6). Throughout the book,
in fact, Dryden consistently refers to writers in other traditions, such as Carl
Rogers and Edward Bordin, thus demonstrating that he is aware of the larger
therapeutic literature.

In reading this book, I was struck by how close the practice of REBT is in
many ways to that of Beck's Cognitive Therapy. But there are differences that
may be mostly stylistic. For example, both ostensibly use Socratic
Questioning. But the examples of this technique found in J. S. Beck (1995)
primarily involve open-ended questions designed to guide the client toward
self-discovery. By contrast, Dryden's examples of Socratic Questioning tend to
use closed-ended questions which can usually be answered by "yes" or "no."
Dryden even includes a Module (16) entitled, "Socratic Disputing of Irrational
Beliefs." Interestingly, however, the words "Socratic Disputing" do not even
appear in the index, being tacitly included under "Socratic Questioning." It is
an empirical question as to which is ultimately the more effective but I
suspect the questioning mode is, at least with most clients.

The book is appropriate for almost-beginners in REBT as well as those

familiar with the basic concepts who want to more systematically develop
their skills. There are some units that appear to be quite basic while most are
rather advanced. Because of the extremely detailed nature of the examples
and practice, this isn't a book that is easy to be implemented after one
reading. Rather, the reader should practice the tasks in each of the modules
repeatedly to be able to use them correctly. In addition, unlike actual
workshops where the trainees can obtain immediate feedback, in using such
a book as this, trainees must provide their own feedback. What this book
demonstrates clearly, however, is that REBT is not a superficial system that
can be quickly and easily put into practice. This book, correctly used, will be
of great help to those mental health professionals wishing to use this type of
therapy well.

[Reference]

REFERENCES

Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford.

[Author Affiliation]

E. THOMAS DOWD

Kent State University

Copyright Springer Publishing Company 2000. Provided by ProQuest LLC. For permission to reuse this
article, contact Copyright Clearance Center

Stress Counseling: A Rational Emotive Approach

From:
Journal of Cognitive Psychotherapy
Date:
January 1, 1999
Author:
Lightsey, Owen Richard Jr
More results for:
REBT

http://www.highbeam.com/doc/1P3-
1474559931.html
Stress Counseling: A Rational Emotive Approach Albert Ellis, Jack Gordon,
Michael Neenan, and Stephen Palmer. New York: Springer Publishing
Company, 1998, 200 pp. Softcover, $32.95 (U.S.), $36.80 (outside the U.S.).
Website: www.springerpub.com

Albert Ellis's vastly influential Rational Emotive Behavior Therapy (REBT) has
been around for some 40 years and is one of the best-known psychological
theories: Hundreds of articles and books have described REBT, and virtually
all counselors and psychologists trained in the United States have been
exposed to the theory in courses, books, and videos. This state of affairs can
constitute quite a hurdle for the aspiring REBT author: What ground is left to
cover?

While Stress Counseling casts REBT within a stress counseling framework,

many of the ideas and techniques elaborated in this book can indeed be
found in many other works such as A New Guide to Rational Living (Ellis &
Harper, 1975) and The RET Resource Book for Practitioners (Bernard & Wolfe,
1993). Given the popularity of REBT, however, a book that details the theory
should be judged not on the newness of the material but on how it succeeds
in engaging and educating. On this score, Stress Counseling delivers.

After a preface by Ellis, Stress Counseling begins with a chapter that

describes the stress process from a REBT perspective. Human beings are
said to create most of their own stress by what they tell themselves about
events. Perception, beliefs, and ineffective behaviors are said to be the key
elements in stress. In effect, then, stress is recast as "distress," the emotional
consequence or "C" (in Ellis's "ABC" rubric) of holding irrational beliefs. This
gives the authors an opportunity to spend most of the remainder of the book
elaborating on counseling within the REBT framework.

In this theory-as chapter 1 illustrates and as most of us know-it is not the

environmental activating event (A) that causes the distressing emotional
consequence (C), but rather our beliefs (B) about the event. Irrational beliefs
lead to undue emotional distress and self-defeating or ineffective behaviors;
rational beliefs lead to appropriate emotion and effective coping. Elevation of
our preferences about ourselves, others, and the world into implicit "shoulds,"
"oughts," and "musts" is said to cause most human distress. For example,
when the preference "I prefer that people like me and treat me fairly"
becomes elevated into the irrational belief "People must like me and treat me
well at all times or they're evil and deserving of punishment," unhealthy
emotions and ineffective behaviors occur. Learning to recognize and dispute
these irrational beliefs and to replace them with rational beliefs leads to
emotional balance and effective action. Chapter 1 proceeds to detail specific
emotions connected with the three major types of irrational beliefs, and ends
with a rather lengthy case vignette that is used to illustrate various REBT
principles and interventions.

Although chapter 1 offers little or nothing "new," it offers a well-organized,

lucid, and readable depiction of distress and REBT. Later chapters of Stress
Counseling are equally clear and engaging in their depiction, respectively, of
assessment; the beginning, middle, and final stages of stress counseling;
additional REBT counseling techniques; brief psychotherapy with crisis
intervention; "How to Deal with Difficult Clients;" and "Occupational Stress
and Group Work." The book ends with a listing of organizations that provide
additional training in REBT. Appendixes contain several very useful forms
and techniques whose applications are detailed in the text.

Stress Counseling is likely to be particularly useful to the practicing counselor

or psychotherapist. For instance, the text depicts specific techniques or
procedures such as "inference chaining" (p. 20), "the 13 steps of the
counseling sequence" (p. 41), and the "money example" for teaching clients
about REBT (p. 48-49); and strategies such as the "three disputing
strategies" (p. 53) and the "Scale of badness" for illustrating that a stressful
event is not "awful" (p. 110). These depictions are illustrated with examples,
typically transcripts of an REBT therapist utilizing the technique or
procedure. All of the familiar aspects of REBT (e.g., the highly directive
counselor, the emphasis on hard work and practice, the use of homework) as
well as common adjuncts (guided imagery, biofeedback, hypnosis, skill-
training) are nicely explained and illustrated.

The text also contains many useful tips for the beginning or advanced
counselor; for example, the authors suggest:

* limiting the definition of the client's consequence (C) to an emotion rather

than a behavior, since behaviors may serve as defenses "to enable clients to
avoid experiencing certain unhealthy emotions" (p. 22);

* rejecting pseudo-feeling terms such as "bad," "stressed," "upset," and

"rejected" by pointing out that there are no such feelings and then by
reiterating a feeling question (p. 23-24);

* avoiding unusual displays of warmth, which in REBT may reinforce clients'

irrational and self-defeating need for love and approval (p. 33);

* warning the client that "relapses" are quite normal and part of the learning
process, and helping the client avoid self-damnation if a relapse occurs (p.
67);

* having the client tape-record counseling sessions or his/her own systematic

self-disputation (p. 68 and elsewhere).

Of particular interest, the authors caution therapists to combat their own

therapyrelated irrational beliefs such as "I have to be successful with all my
clients practically all the time" and "I must be an outstanding therapist" (p.
124), for such beliefs may interfere with effective counseling.

Stress Counseling also offers brief but interesting suggestions for applying
REBT with specific client problems such as substance abuse, posttraumatic
stress disorder, personality disorders, and eating disorders. The final chapter
provides brief illustrations of how REBTmay be used in treating work-related
stress. Though too brief and general to serve as intervention guidelines,
these examples contain several interesting suggestions. In this regard, the
authors suggest that one may use inference chaining, or "in-session voluntary
hyperventilation" to good effect with persons who suffer from panic disorder.
Inference chaining can help such clients unearth the irrational beliefs that
lead to panic, while in-session deep-breathing can help them learn to
reattribute symptoms to rapid breathing rather than to "heart attacks" or
other feared events.

Beyond techniques and applications, Stress Counseling offers a number of

interesting hypotheses that logically follow from REBT but that I have not
seen in print. For example, in a discussion of personality variables such as
dispositional optimism, the authors contend that such characteristics
"encourage people to create various kinds of irrational cognitions about the
negative life events or stressors in their lives" (p. 5). If the authors are
referring to optimism per se, their argument appears to be at odds with
empirical evidence for the benefits of optimism. However, their comments
also suggest the broader possibility that personality characteristics exert their
influence via an effect on cognitions and beliefs. For example, dispositional
tendencies toward optimism or positive emotion may lead to psychological
and physical benefits by increasing the probability that we react to stressors
with more "rational beliefs" and fewer "irrational beliefs." This argument
deserves careful empirical scrutiny.

In another interesting observation, the authors argue that "therapists need to

be able to distinguish what Beck and his colleagues term "automatic
thoughts", or what REBT theory refers to as inferences, on the one hand, and
Irrational Beliefs, on the other" (p. 19). The authors then illustrate "Inference
Chaining" and other procedures designed to help the counselor work down
through levels of inference in order to excavate and change clients' core
irrational beliefs, which are the proper targets of REBT. The authors make
similar points in other chapters, suggesting for example that increasing the
client's "positive thinking" has "distinct limitations" (p. 91) and may be of
limited use without forceful attempts to change core irrational beliefs.

Stress Counseling is a practical guide rather than a theoretical or scientific

treatise. Readers who seek a scholarly review of empirical evidence regarding
REBT or an elaboration of new theoretical developments will be disappointed.
Additionally, some ideas such as the basic REBT sequence and the three
emotional consequences of irrational beliefs recur a number of times in the
text, and some examples have a rather restrained flavor that may not "ring a
bell" for American readers. In this regard, the idea that not tipping a bad
server could produce an onslaught of irrational beliefs and "shame" and thus
could serve as a "shame attacking exercise" may strike some Americans as
amusing.

Overall, however, Stress Counseling is a useful book that has renewed my

appreciation for an approach that I have known and used for some 18 years.
As professional basketball players continue to practice the core skills of
shooting, dribbling, and passing, and thus to continually improve their game,
seasoned counselors would do well to regularly "return to the basics" and
apply the core ideas of REBT. Stress Counseling provides a solid means of
doing so. It should appeal not only to counselors-in-training but also to
professional counselors and to those who train counselors and psychologists.
After 40 years, REBT is stronger and more applicable than ever.

[Reference]

REFERENCES

Bernard, M. E., & Wolfe, J. (1993). The RET resource book for practitioners.
New York: Institute for Rational-Emotive Therapy.

Ellis, A., Gordon, J., Neenan, M., & Palmer, S. (1998). Stress counseling: A
Rational Emotive approach. New York: Springer Publishing Co.

Ellis, A., & Harper, R. (1975). A new guide to rational living. North Hollywood,
CA: Wilshire.
[Author Affiliation]

Offprints. Requests for offprints should be directed to Owen Richard Lightsey,

Jr., Department of Counseling, Educational Psychology and Research, The
University of Memphis, 100 Ball Education Building, Memphis, TN 38152.

OWEN RICHARD LIGHTSEY, JR.

The University of Memphis

Copyright Springer Publishing Company 1999. Provided by ProQuest LLC. For permission to reuse this
article, contact Copyright Clearance Center.

Fostering Emotional Adjustment among Nigerian

Adolescents with Rational Emotive Behaviour
Therapy
From:
Educational Research Quarterly
Date:
March 1, 2006
Author:
Adomeh, Ilu O C
More results for:
APPLICATION OF REBT AND SELF ESTEEM

http://www.highbeam.com/doc/1P3-
1161697701.html
This study examined the efficacy of Albert Ellis' Rational Emotive Behaviour
Therapy (REBT) in fostering emotional adjustment among Nigerian
adolescents. Fifty senior secondary school students were randomly selected
and divided equally into experimental and control groups. The experimental
group was treated with REBT twice a week for six weeks. The result indicated
that REBT effectively reduced the levels of anxiety and stress of the
adolescents. Although the experimental group's level of depression dropped,
the reduction was not statistically significant. Implications for counselling the
Nigerian adolescents includes using the REBT principles to draw up a
treatment programme for treating identified maladjusted adolescents within
the classroom and using it to manage the classroom climate in order to
facilitate the teaching/learning process.

Rational-Emotive Behaviour Therapy (REBT) as developed by Albert Ellis is

the application of reason and logic to psychotherapy. It is a rational problem
solving approach, which Ellis directed to personal behaviour problems. Ellis
was convinced that irrational neurotic early learning persisted in human
memory rather than being extinguished if they were not reinforced. He
therefore decided to teach his clients to change their aberrant thinking styles
and give rational explanation to their behavioural problems (Ellis, 1962).

Anxiety, depression and stress are emotional adjustment problems that affect
the adolescents and the society, which this study focuses on. The emotionally
maladjusted adolescent is an unhappy adolescent. And his problems certainly
demand attention if for no other reason at least on humanitarian grounds.
Since the dividing line between the emotionally maladjusted adolescent and
juvenile delinquent adolescent could be a very tenuous one, the former may
be considered as unidentified delinquent. Since both the maladjusted
adolescent and the juvenile delinquent are societal problems there is the
need to assist them out of their problems and make them socially accepted
members of the society. This study aims at using a clinical technique like
Rational Emotive Behaviour Therapy to assist emotionally disad vantaged
adolescents to develop adaptive behaviour within and outside the classroom.

Literature Review

Counselling belongs to a special domain of psychology in applied setting. In

Nigeria and most developing countries of the world, it is relatively anew
discipline. Counselling is a part of guidance. And guidance is a helping
process which aims at assisting persons to understand themselves and their
world, solve their problems and adjust to life both emotionally and physically.
Counselling is the pivot of the guidance programme. It is meant to effectively
change human behaviour so that the recipients may live self-satisfying and
productive lives (Shertzer & Stone, 1976). Thus the reason why counselling
programmes are being organized in Nigerian schools is to help students to
understand themselves and their world so as to become adjusted and self-
directed individuals. The foundations of counselling therefore are human
growth and development. According to Peck (1981) there is, however, a
general lack of interest in the education of emotionally disturbed children.
The reasons are because of the tendency to refer them to clinicians for
psychotherapeutic treatment and more recently, the tendency to apply
'special education' to emotional disturbance in children. But what, or who are
emotionally disturbed adolescents? Generally, definitions of emotionally
disturbed adolescents have pivoted on the following considerations:
hyperactivity, withdrawn behaviour, failure to achieve at a level reasonably
commensurate with ability, resentment, learning difficulties, aggressiveness,
lack of concentration and inability to relate with others satisfactorily
(Gearheart, 1974; Peck, 1981; Adima, 1989).

Other definitions are based on social, cultural and clinical education factors.
Thus when we experience something, which makes a lasting impression on
us, the feeling we evoke is emotion. Emotions are relatively brief and they are
evoked in response to re-creation of an event that embarrassed us in the
past and in remembering such event, we are embarrassed again. The nature
of the emotion depends on the nature of the stimulus. This ranges from the
ecstasy people feel when they fall in love, through the joy people feel during
wedding to the grief people feel at funeral (Calson, 1993).
Ellis' (1962) basic assumptions about human nature are that:

1. Man is uniquely rational, as well as irrational. When he is thinking and

behaving rationally, he is effective, happy and competent. In other words,
Ellis believes that man has the capabilities to adjust to life situations. Thus
when man wants to be effective, happy and competent, he must think and
behave rationally. If on the hand, he is ineffective, unhappy and incompetent,
it means he is thinking and behaving irrationally. It is however, not true that
things always go the way Ellis proposed.

2. Emotional or psychological disturbance - neurotic behaviour - is a product

of irrational and illogical thinking. Thought and emotion are the same;
emotion accompanies thinking and it is biased, projected and highly
personalised thinking. Ellis however missed the point when he concluded that
thought and emotion are co-extensive; and that emotion always accompanies
thinking in a biased and projected form. If this is true, no thinking will be
rational. This certainly contradicts Ellis' first assumption, which declared man
as both rational and irrational depending on his form of thinking.

3. Irrational thinking originates in the early illogical learning that the

individual was exposed to by his parents and his culture. It is true that some
irrational thinking could originate from early illogical learning that the
individual was exposed to by either his parents or culture; however, not all
illogical and irrational thoughts arise in this way.

4. Since human beings are verbal animals, the phrases and sentences that
we keep telling ourselves frequently are or become our thoughts and
emotions. Thus any human being who gets disturbed is telling himself a chain
of false sentences. Here again Ellis went too far in his assumption.
Internalised sentences could sometimes lead to emotion, but not all emotions
are the end products of self-talk.

5. Continuing state of emotional disturbance is as a result of self-

verbalisations, not by external circumstances or event, but by the
perceptions and attitudes towards these events that are incorporated in the
internalised sentences about them. This fifth assumption is similar to that of
Epictetus that people are disturbed not because of events but because of
their attitudes towards these events.

6. Negative and self-defeating thoughts and emotions must thus be attacked

by reorganised thoughts so that thinking becomes logical and rational rather
than irrational and illogical. This assumption places a great responsibility on
the therapist. He is required to apply reason, logic, suggestion, teaching,
confrontation, indoctrination, de-indoctrination, persuasion and prescription
of behaviour to show the client what his irrational philosophies are and the
need to change his thinking. Thus unlike Carl Rogers' Client Centred Therapy,
Ellis' RET is authoritarian, directional and brainwashing.

In spite of these shortcomings inherent in his assumptions, Ellis wittingly or

unwittingly decided to prove to his clients that emotional problems of
maladjustment stem from illogical and irrational thoughts. He believes firmly
that by maximising one' intellectual power, one can free oneself of emotional
disturbances. In effect, if the principles outlined in REBT are applied to
adolescents' emotional maladjustment, it may be possible to effectively
foster emotional adjustment among them.

Adima traces the problem of emotional adjustment in adolescents to the

following factors, namely, brain injury, negative environmental influence,
poor academic performance, parental deprivation, loose or strict upbringing,
unfavourable school condition, adult negative influence and excessive use of
psychoactive drugs (cf. also Adomeh, 1997).

On the effectiveness of counselling, Filani (1984) reported his successful use

of Rational-Emotive Therapy in the treatment of a client with depressive
illness. The client, according to Filani (1984) had multiple problems ranging
from headache, chest and body pains to dreadful dreams. Although previous
medical examinations detected no abnormality in her, velum 5mgm and
multivate tablets were recommended for her use. The therapist discovered
that her problem began when she lost her son the previous year. After having
four treatment sessions with her for a period of four weeks, she reported that
she was no longer depressed.

Although studies abound on the effectiveness of counselling ( Morakinyo,

1986; Adomeh, 1997; Aluede & Maliki, 1999) its overall importance is still
questionable. This point is illustrated well in an analogy put forward by
Willems (1973). Aspirin, Willem says, relieves a person of headaches. But the
absence of aspirin we know does not cause headache. Similarly, while
counselling could help to foster emotional adjustment among adolescents, it
does not necessarily imply that emotional maladjustment among adolescents
is caused by misguided treatment or absence of treatment. It is therefore
imperative to stress the need to avoid the circular argument that unexplained
behaviour changes occur as a result of faulty behavioural or counselling
procedures (Nwabuoku, 1980).

In pursuit of the aforementioned objective, the study sought to establish ihe

efficacy of Rational Emotive Behaviour Therapy in fostering emotional
adjustment among Nigerian adolescents. The major research question of this
study therefore was, how effective is Rational Emotive Behaviour Therapy in
fostering emotional adjustment among adolescents? In other to adequately
address this core question, the following sub-questions have been raised in
this study:

1. Is there difference in the level of anxiety between research participants in

the experimental group and those in the control group?

2. Is there difference in the level of depression between research participants

in the experimental group and those in the control group?

3. Is there difference in the level of stress between research participants in

the experimental group and those in the control group?

Method Of Study
The experimental design adopted for this study is the Post-test-only Control
Group Design. The systematic random sampling method was used to select
twenty-five adolescents each into the experimental and control groups.
Subjects in the experimental group were treated with REBT twice a week for
six weeks with each session lasting one hour. The instrument used for the
study was the Odebunmi (19991) Anxiety, Depression and Stress scales in his
Psychological test for counselling and health management, which has a
concurrent validity of 0.50 at P <.01 level of significance.

Results

The results of the study indicated that the first hypothesis, which states that
there was no significant difference in the level of anxiety between research
participants in the experimental group and those in the control group, was
rejected (t = 2.92, P<0.05). From the inspection of the means, it was
discovered that the experimental group (M= 49.9, SD= 13.7) had a lower
level of anxiety when compared with that of the control group (M= 46.4, SD=
6.16).

The results of the study indicated that the second hypothesis, which states
that there was no significant difference in the level of depression between
research participants in the experimental group and those in the control
group, was accepted (t = 0.56, P<0.05). From the inspection of the means, it
was discovered that the experimental group (M= 46, SD= 6.16) had a similar
level of depression when compared with that of the control group (M= 45.6,
SD= 6.92).

The results of the study indicated that the third hypothesis, which states that
there was no significant difference in the level of stress between research
participants in the experimental group and those in the control group, was
rejected (t = 2.26, P<0.05). From the inspection of the means, it was
discovered that the experimental group (M= 48.2, SD= 12.6) had a lower
level of stress when compared with that of the control group (M= 45.6, SD=
5.28).

Discussion Of Results

The finding of this study indicated that there was a significant difference in
the level of anxiety between research participants in the experimental group
when compared with those in the control group. In effect, the counselling
method, namely, Rational Emotive Behaviour Therapy (REBT) employed in
the present study proved effective in reducing level of anxiety. The reason
why the treated subjects improved significantly on their level of anxiety can
be explained with the argument that anxiety, as adolescents' emotional
adjustment problem is amenable to psychological treatment. Moreover, REBT
assumes that man is uniquely rational, as well as irrational. When he is
thinking and behaving rationally, he is effective, happy and competent. The
REBT package in this study was used to make the subjects know this and
they were made to incorporate this assumption into their thinking system.
Since they accepted that their level of anxiety could be reduced when they
think logically and rationally, it is not surprising therefore that treated
subjects have lower level of anxiety than subjects in the control group.

This result supports the view that adolescents' emotional adjustment

problems can be solved psychologically. This present finding also
corroborated the result of earlier studies on efficacy of counselling in treating
clients with emotional problems (Nwabuoku, 1980; Adomeh, 1997). As
indicated by the present study's result, counselling is certainly superior to
non-treatment condition as far as reduction of level of anxiety among treated
adolescents is concerned. Studies already cited which support the
effectiveness of psychotherapy in reducing the level of anxiety, are further
supported by the result of this study. The efficacy of counselling in fostering
emotional adjustment among treated subjects is one of the basic reasons the
use of psychological tests is popular in counselling. The stand of the present
researcher therefore is in support of the aforementioned researchers' position
that less severe anxiety could be modified through psychotherapy.

The second finding indicated that no significant difference was found in the
level of depression between research participants in the experimental group
and those in the control group. On the basis of this finding, the claim of Ellis
that REBT produces better results when applied to clients' emotional
behaviour problems (Palmer, Dryden, Ellis and Yapp 1995) does not appear to
be supported here. The result of this present study does not suggest the
superiority of a treatment condition over a no treatment situation. The
assertion of Eysenck (1952, 1955, 1960; 1961) cited by Nwabuoku (1980)
and Adomeh (1997) over the years that counselling is not superior to a
situation were there is no treatment can be revisited here. Although more
evidence has been found by researchers in the field of counselling pointing to
the efficacy of psychotherapy (Filani, 1984; Morakinyo, 1986 and Adomeh,
1997) the result of the present study dealing on the reduction of level of
depression via REBT calls for caution. Since it is impossible to resolve the
debate philosophically, it is advisable to adopt any of the several positions
that have been vigorously advocated in this connection.

Another result of this study indicated a significant difference in the level of

stress between research participants in the experimental and control groups.
The implication of this is that REBT as a counselling method is effective in
reducing the level of stress among treated subjects. The significant
difference in the level of stress between the treated and non-treated
adolescents can be explained by the fact that stress is a well-known health
problem. Sometimes stressful situations lead to psychosomatic as well as
gastrointestinal reactions such as peptic ulcer. Lack of concentration and low
academic achievement could result from stress. The adolescent that had
been told that his academic performance could improve if he or she is less
stressful would generally embrace any coping means of doing so. The
counselling strategy employed in this study was presented to the treated
subjects as such coping means.

Moreover, the subjects of study were aware of their situational demands and
the need to acquire effective adjustment skills as basic requirements for full
human functioning. They were also aware that adherence to the demands of
adjustment would enable them to adapt to their environment. Such demands
require that they make a choice which would led them to a rewarding future
thus they preferred making a choice by applying REBT strategy to stressful
situations. The result is a reduction in level of stress in their lives. The finding
thus attests to that of Palmer (1992) who found that the application of
RET's A-B-C-D-E paradigm and relaxation techniques to stressful situations
proved effective stress management strategies.

Implications for counselling the Nigerian adolescents

The effectiveness of the counselling orientation employed in this study has

far reaching implication for guidance and counselling in our educational
setting. In this study, the Rational Emotive Behaviour Therapy (REBT) has
been found to be useable and effective in treating adolescents' emotional
adjustment problems. With those findings, Guidance Counsellors now have a
handy technique for treating identified adolescents' emotional adjustment
problems. Using this technique in treating adolescents' emotional adjustment
problems would save a lot of time on the part of the School Counsellor.

The effectiveness of REBT found in this study in respect of reduction of

levels of anxiety and stress among treated adolescents is a step forward in
psychological research in our school system. Practicing Counsellors in Nigeria
can continue in this area in their own ways so that they can either confirm
the findings of this study or reject them. The emotionally maladjusted
teenagers are according to Adima (1989) found almost in every classroom;
yet the school curriculum does not make special or adequate provision for
their training. The School Counsellor can use the principles of REBT outlined
in this study to draw up a treatment programme for such adolescents when
identified.

In schools, especially in the developing nations of the world, where neither

Guidance Counsellors nor Para-counsellors are not available, the classroom
teacher whose aim is the effective management of the classroom climate in
order to facilitate the teaching/learning process can adopt REBT as a
counselling method for such a purpose. Researches have indicated that not
all disturbing students require prolong psychological treatment (Adima, 1989;
Gearheart, 1974). What the student might require at the on set might just be
the teacher's attention or reassurance. The teacher can easily do that
through the use of REBT.

Since there is a dearth of Guidance Counsellors in many schools in the

developing world, knowledge of the efficacy of REBT in fostering emotional
adjustment among teenagers has counselling implication for the students.
The students can easily use the counselling orientation employed in this
study even in the absence of Counsellors. Teaching the students to use REBT
as a counselling method was an implied goal in this study. This goal was
achieved through assignment of home works to members of the
experimental group during the fieldwork. At the end it proved to be very
useful.
Although Ellis' Rational Emotive Behaviour Therapy (REBT) as a counselling
technique is highly philosophical, it is possible to use it to foster emotional
adjustment among Nigerian adolescents. What is required of the therapist is
to apply reason, logic, teaching, persuasion, suggestion, confrontation and if
necessary, prescription, indoctrination and de-indoctrination so that the client
can understand why he must change his irrational thinking which is the
source of his problem. Although this task is an enormous one for the
therapist, the result is equally great, as the adolescent would be effective,
happy, rational and competent.

[Reference]

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Adima, E.E. (1989). Special Education, Ibadan: NPS Educational Publishers,

Ltd.

Adomeh, I.O.C. (1997). Differential effectiveness of two counseling methods

of fostering emotional adjustment among adolescents. Unpublished Ph.D.
Thesis.University of Benin, Benin City.

Aluede, O.O. & Maliki, A. (1999). Rational Emotive Behavior Therapy:

Implications for counseling the Nigerian school child, Journal of Nigerian
educational research association, 13(1). 1-8.

Calson, NR. (1993). Psychology: The science of behavior, Cambridge,

Massachusetts: Winthrop Publishers, Inc.

Ellis, A. (1962). Reason And Emotion in Psychotherapy, New York: Lyle Stuart
Filani, T.O. In (1984). Mental Health adjustment Through Psychological
Treatment in Nigeria. Psychology For every-Day Living: A Nigerian. Journal of
Applied Psychology. 3(1)9-19.

Gearheart, B.R. (1974). Organization and administration of educational

programs for exceptional children, Springfield, Illinois: Charles C. Thomas.

Morakinyo, A (1986). Improving academic performance via anxiety reduction.

Nigerian Journal of Educational Psychology. 1(1) 73-83.

Nwabuoku, F.U. (1980) The differential effectiveness of two counseling

strategies on a group of Nigerian adolescents. Unpublished Ph.D. Thesis.
University of Ibadan, Ibadan.

Odebunmi, A (1991). Psychological tests for counseling and health

management, "Answer Key" (2nd Impression). Abeokuta: Sodipio Press Ltd..

Palmer, S., Dryden, W., Ellis, A & Yapp, R. (1995). Rational interviews, London:
Centre For Rational Emotive Behaviour Therapy.

Peck, D.G. (1981). Adolescent self-esteem: Emotional learning disabilities

and significant others. Adolescence, XVI, 62,443-451.
Shertzer, B. & Stone, S.C. (1976). Fundamentals of guidance, (3rd Edition)
Boston: Houghton Mifflin Company.

Weiten, W. (1992). Psychology: Themes And variations, Pacific Grove,

California: Brooks/Cole Publishing Company.

Willems, P. (1973) Stating the basis of counseling. California :Guidance

Association Monograph, I.

[Author Affiliation]

Ilu O. C. Adomeh

Ambrose Alli University

Copyright Educational Research Quarterly Mar 2006. Provided by ProQuest LLC. For permission to reuse
this article, contact Copyright Clearance Center.

EFFECTIVENESS OF RATIONAL-EMOTIVE
EDUCATION: A QUANTITATIVE META-ANALYTICAL
STUDY
From:
Journal of Cognitive and Behavioral Psychotherapies
Date:
March 1, 2007
Author:
McMahon, James; Vernon, Ann; Trip, Simona
More results for:
APPLICATION OF REBT AND SELF ESTEEM

http://www.highbeam.com/doc/1P3-
1238577871.html
Abstract

Research on Rational Emotive Education (REE) is not as prolific as in Rational

Emotive Behavior Therapy (REBT), on which it is based. No quantitative
meta-analytic studies of REE were found in the literature; in fact, we found
only 6 reviews on REE. The objective of this study was to investigate the
effectiveness of REE through a quantitative meta-analitical study. Twenty-six
(26) published articles, which fit the inclusion criteria, were examined. Results
demonstrated that REE had a powerful effect on lessening irrational beliefs
and dysfunctional behaviors, plus a moderate effect concerning positive
inference making and decreasing negative emotions. The efficiency of REE
appeared to not be affected by the length of applied REE. Rather, the REE
effect was strong when participants were concerned with their problems.
Types of psychometric measure used for irrational beliefs evaluation affected
the results. Effect sizes increased from medium to large when the subjects
were children and adolescents compared to young adults.

Key words: Rational Emotive Education, quantitative meta-analysis,

effectiveness.

INTRODUCTION

Compared to research on Rational-Emotive Behavior Therapy (REBT), the

research concerning Rational-Emotive Education (REE) seemed not to be
nearly so ubiquitous. Searches of ERIC, EBSCO, and PsychInfo based on the
key words rational emotive education enabled the writers to discern the
following:

1) for the 1970s, twenty-one (21) published articles, 2 books and 10

dissertations were located;

2) in the 1980s, Rational-Emotive Education (REE) was the topic for thirteen
(13) published articles, 2 book chapters, and eighteen (18) dissertations;

3) between 1990-2006, the search revealed thirty-one (31) published articles,

2 book chapters, and fourteen (14) dissertations.

No quantitative meta-analytic studies of REE were found in the literature.

Only 6 reviews were found as qualitative meta-analytic studies (DiGiuseppe,
Miller, & Trexler, 1977; DiGiuseppe & Bernard, 1990; Gossette & O'Brien,
1989; Gossette & O'Brien, 1993; Hajzler & Bernard, 1991; Watter, 1988). Four
of them presented data (percentages) about the efficiency of REE. The
review studies by Gossette and O'Brien (1993) were the most critical and
their advice was that it seemed fruitless for anyone to undertake REE
research.

DiGiuseppe, Miller, and Trexler (1977) reviewed Maultsby and his other
studies (Maultsby, 1974; Maultsby, Knipping & Carpenter, 1974; Maultsby,
Costello & Carpenter) that argued that Rational-Emotive Education was an
efficient prophylactic against mental deterioration among non-clinical
populations of children and adolescents. Other studies reviewed by them
asserted that the children involved in an REE program were able to learn the
REBT assumptions, to modify their irrational beliefs, and to have more
functional emotions and behavior than they had before REE.

Watter (1988) analyzed the research that had been done after the dates of
those cited in the previous paragraph on Rational-Emotive Education. Watter
concluded that elementary school pupils who attended REE had modified
their anxiety levels, increased self-esteem, and raised low frustration
tolerance (LFT) toward high frustration tolerance (HFT). Generally, such
students became more skilled at coping with emotionally loaded situations.
Compared to an educational program based on elements of Freudian theory
as well as with a sex education program, REE was helpful for students to
decrease irrational beliefs and dysfunctional emotions.
Gossette and O'Brien (1989; followed by Gossette & O'Brien, 1993) judged
that the studies that had been conducted on REE did not offer enough data to
support the possibility of efficiency with school populations. The major effect
of REE was on irrational beliefs, as was expected. Their judgments were not
surprising because the content of irrational beliefs measuring scales was
identical with the content of the REE curriculum. Minor modifications were
found on behaviors: students with problems not covered in the curriculum
were less receptive to REE than students who at the outset reported no
problems.

DiGiuseppe and Bernard (1990) found that more then 90% of the studies
they reviewed supported REE efficiency in diminishing irrational beliefs. More
then 50% of the studies sampled recorded behavior modification, locus of
control internalization, changes for various personality styles and concerning
some development milestones. Fifty per cent of the studies surveyed by
these researchers supported anxiety levels having decreased while self-
esteem increased (which could further have supported an ipsilateral
statistical artifact in that as one score decreased another increased). The idea
that the emotional and behavior change was due to beliefs modification could
not be inferred from the results of any single study. However, REE had a
higher potential for changing adaptive functioning than for changing any
single, targeted behavior.

Hajzler and Bernard (1991) asserted that irrational beliefs decreased in 88%
of the studies they surveyed, while locus of control internalized in 71% of the
studied undertaken with students who displayed learning problems. They
reported that anxiety waned in 80% of the studies surveyed, while self-
esteem and general adaptation (functional behaviors) improved in 50% of
cases.

Gossette and O'Brien (1993) analyzed thirty-three dissertations and 2

published articles concerning REE. That survey showed some greater
efficiency in managing irrational beliefs (53%), with irrational beliefs
modification (43%) for managing neuroticism, and less than 30% of subjects
for managing emotional and behavioral consequences. Based on these
results the authors concluded that perhaps the basic principle of the REE
model was troubling and that, ". . .the continued use of REE in the classroom
with normal school children is unjustified and in fact contraindicated"
(Gossette & O'Brien, 1993, p.23). David et al., (2005) classified this study as
being biased and its conclusions wrong - the fact that Rational -Emotive
Education was 30% less efficient than the other treatments (including group,
placebo group, and other interventions) was a misinterpretation of the data;
the correct conclusion would be that Rational-Emotive Education at least as
effic ient as other treatments and more efficient than other treatmentas
about 30% of the time. The objective of this study was to investigate the
effectiveness of REE through a quatitative meta-analitical study.

METHOD

Selection of Studies
The selection of studies was done by searching ERIC, EBSCO, and PsychInfo
from 1970 to 2006, using the key words rational emotive education. The
reference list of articles included in previous reviews was also used. To be
included in the meta-analysis, each study had to fulfill the following criteria:

1. it had to be published in a specialty journal, which meant they were at

least edited or edited-peer reviewed (therefore, dissertations were not
included);

2. at least one study group had to involve REE and that program had to be
clearly described;

3. the selected article had to offer pretest-posttest or REE - control, placebo,

or other intervention group comparisons;

4. the article had to have statistical data to support the main effects;

5. the number of subjects for each group studied had to be specified.

A total of 26 studies, which met the above criteria, were identified and
included in the present quatitative meta-analysis

Main Effect Estimations

Differences between means evidenced in transformed scores were

calculated, using Cohen's "d" estimate for the effect size. Different people
offer different advice regarding how to interpret the resultant effect size, but
the most accepted opinion is that of Cohen, where 0.2 is indicative of a
small/low effect, 0.5 a medium, and 0.8 a large/powerful/strong effect size.
The formulae used for d calculation were: (1) d = the mean of difference
scores divided by the standard deviation of difference scores (related
samples), and (2) d = (experimental group mean - control group mean) /
intra-group standard deviation (independent samples). The intra-group
standard deviation was derived from the intra-group variance, that formula
supported by Fisher (Hunter & Schmidt, 1990). Where the means and
standard deviations were not offered, d was calculated based on t, r, F or ?2
scores, that procedure having been supported by Hunter and Schmidt (1990).

Coding System

After having been selected, the studies were analyzed following these
categories of variables: independent, moderators, and dependent, using the
coding system proposed by Smith et al., (1980, as cited in Hunter & Schmidt,
1990). The independent variable was the treatment offered: Rational-Emotive
Education was compared with the baseline level, control group (e.g., no
treatment, waiting-list), placebo group, or other intervention (i.e., self-
instructional training, human relationships, experiential training, and
relaxation). Included in the moderator categories were the following
variables: age (i.e., children, adolescents, students), measures, intervention
length (i.e., short, medium, long), as well as subject diagnosis (i.e., no
problems, academic problems, behavior disorders, anxiety). The dependent
variables were: irrational beliefs, inferential beliefs (i.e., cognitive distortions -
cold cognitions), emotions, and behaviors (see David, 2003 for details).

RESULTS AND DISCUSSION

REE was analyzed for its effect on different dependent variables. Table 1
shows the values of the effect size of REE on irrational beliefs, inferential
beliefs, emotions, and behaviors. Significant differences were found between
groups: F (3, 202)=2.85, p<.05, as REE seemed more efficient with irrational
beliefs and behavior modification. The effect size seemed powerful
concerning decrease in dysfunctional behaviors, and partially powerful with
irrational beliefs modification, and adequately powerful statistically
concerning inferential beliefs and changing emotions.

Table 2 shows no significant differences between the independent variables, F

(3, 202)=1.06, p>.05. The effect size was medium when REE was compared
with the baseline, control group and placebo group. The effect size was large
when REE was linked to other interventions (i.e., relaxation, human
relationship, self-instructional training, experiential therapies).

The results showed that the benefit of the REE participants maintained gains
in the follow-up phase compared with the control group and other
interventions (human relationship): d=2.69 [s.d.=2.17; 95% - (-1.56 - 6.94);
276 subjects; 9 comparisons].

The efficiency of REE seemed not to be influenced by length of training (see

Table 3). A short length was considered less then 4 meetings (50 min. - 1
hour), while medium length was taken to mean 4-17 meetings (50 min.- 1
hour), and the long length was 17 - 85 lessons (30 min. - 1 hour). Even
though the effect size became larger and larger as the length of training
grew, the differences were not statistically significant (F (2, 43)=2.54, p>.05.

Other moderator variables that seemed to influence the efficiency of REE

were the diagnostic characteristics of the population involved. REE was an
efficient program of secondary prevention with different subclinical problems
manifested by children and adolescents. The problems studied in the
research involved in this meta-analysis can be arranged in 3 categories: (1)
academic problems including learning problems; school withdrawal; low
academic performance; (2) behavioral problems; and (3) anxiety (test anxiety
and state-trait anxiety). No differences (see Table 4) were found between the
categories (F (2, 14)=2.44, p>.05). The effect size was the largest for
academic problem solving. A powerful effect size was obtained concerning
anxiety reduction. An average effect size was recorded with behavioral
problems decreasing. The effect size of REE seems to have supported even a
primary prevention program that aimed to reduce the strength of dependent
variables (irrational beliefs, dysfunctional inferential beliefs, emotions, and
behaviors) in a normal population (i.e., no problems).

An age effect was also revealed (see Table 5): REE was more efficient in
working with children and adolescents compared to working with
undergraduate or graduate students F (2, 204)=4, p<.05.
Furthermore, the age moderator effect on different dependent variable
decreased through REE (see Table 6). Even though the effect size was large
for children, no age effect was revealed for irrational beliefs F (2, 37)=2.29,
p>.05. The same pattern of results was obtained for inferential beliefs F(2,
36)=1, p>.05, emotions F(2, 59)=1.72, p>.05, and behaviors F(2 ,62)=2.46,
p>.05. The effect size was powerful for irrational beliefs and emotions
modification with children, adequate for the inferential beliefs, and low for
behaviors; however, the differences were not statistically significant (F (3,
49)=2.7, p>.05). For the adolescents, REE benefits were higher on behavior,
but again no significant differences were found between the dependent
variables (F (3, 96)=1.89, p>.05). The effect size value was adequate for
irrational beliefs, inferential beliefs, and emotions. No variation of the effect
size was recorded for young adults; the values of effect size for young adults
were close to medium (F (3, 49)=3, p>.05).

It seemed reasonable for the present writers to learn if the values of REE
effect size on the dependent variables were different in function of the
independent variables (see Table 7). As was expected, REE was more efficient
than other interventions (i.e., relaxation, human relationship, self-
instructional training, and experiential training) in irrational beliefs
modification; the effect size was large. Significant differences between
designs (e.g., REE vs baseline, REE vs control group, REE vs placebo, REE vs
other interventions) were obtained F (2, 36)=39.20, p<.01. The effect size
value was adequate when REE was compared with its baseline, or to a
control, or to placebo.

The same values were recorded for dysfunctional inferential beliefs when REE
was compared with the control and placebo groups. There were significant
differences between the four modalities of independent variables: F (3,
35)=10, p<.01; the effect size was low when REE was linked to its baseline
and other interventions.

No differences seemed evident for emotions (F (2, 59)=0.5, p>.05) and

behaviors F (2, 62)=2.18, p>.05. The evolution of effect size values seemed
relatively constant for emotions. REE seemed to be more efficient regarding
modification of dysfunctional behaviors when it was compared with its
baseline and other interventions.

Table 8 presents the impact of REE on irrational beliefs. A large effect size
resulted for The Idea Inventory, Children's Survey of Rational Beliefs, and The
Adulat Irrational idea. For the rest of the instruments, the effect size was
average. It therefore can be concluded that the results regarding REE
efficiency were influenced by the quality of the instruments used.

The next table (see Table 9) presents the results of REE effect on different
inferential beliefs. Locus of control is one of them, measured in all the
involved studies with Nowicki - Strickland Internal - External Control Scale.
Under the category of self-concept, self-esteem, self-description, and the
selfconcept were grouped. Personal orientation and self-control are
representatives for the third category of inferential beliefs. The forth category
is given by attributions and self-efficacy (they were variables only in one
study) Significant differences were found between inferential beliefs
categories F (3, 35)=14, p<.01. The effect size was higher for locus of control
and self-concept then for personal orientation, self-control and attributions,
self-efficacy. REE seemed to be more efficient in locus of control
internalization and a positive self-concept development.

Significant differences (see Table 10) were found for emotions F (5,
56)=32,25, p<.01. The effect size was large in modification of concern and
emotionality related to test anxiety. Average to large effect sizes were
observed in anger modification. Anxiety (i.e., test anxiety, state-trait anxiety)
decreases revealed an average effect size. REE has alower effect size in
lessening neuroticism and negative mental health indices.

The differences between the effect size of REE on different behaviors were
also significant F (6, 56)=45.03, p<.01. A very large effect size (see Table 11)
was revealed on playing hookey from school, behavioral problems, GPA, and
relationship with others. An average value of the main effect value for REE on
academic performance was measured on standardized tests, academic
interest, and achievement-motivation. The REE seemed not to be as efficient
in assertiveness modification.

CONCLUSIONS AND DISCUSSION

The results of this quatitative meta-analysis generally supported the efficacy

and effectiveness of REE. Unlike some previous studies (e.g., Gossette &
O'Brien, 1993) the results encouraged even further research in REE. Gosette
and O'Brien's comments seemed antagonistic toward psychoeducational
research, and their reasoning seemed shoddy based on 35 particular cases
(until 1993 there were more then 55 unpublished dissertations and published
research articles). Thus, they underestimated possible future REE research
potentials through their biases. They also ignored the research on REBT,
arguing that the principle of the model was wrong. Finally, they totally
ignored the notion of primary prevention. This meta-analysis also sustained
the argument made by David et al., (2005) concerning the biases of the
Gossette and O'Brien' studies.

REE had a powerful effect on lessening irrational beliefs and dysfunctional

behaviors, plus a moderate effect concerning inference and decreasing
negative emotions. These results were similar to conclusions made by
DiGiuseppe & Bernard (1990) who noted that REE was more efficient then
other interventions concerning irrational belief modifications. DiGiuseppe and
Bernard (1990), as well as Hajzler and Bernard (1991), found reasonable
support for REE's efficacy on anxiety. Our results also supported a medium to
low REE effect on neuroticism.

In conclusion, based on this first quantitative meta-analysis on REE, REE does

have significant effects on a number of variables. It can be concluded that
REE is a viable approach that can affect negative emotions and behaviors, as
well as lessen irrational beliefs and dysfunctional behaviors. However, to
strengthen this conclusion and to fully explore the potential of REE,
shortcomings of REE research need to be corrected, and high-quality studies
should be implemented and better promoted. More attention should be paid
to generic methodological criteria such as (a) formal clinical assessment of
psychopathology; (b) adherence to/adequacy of REE protocols; (c) measures
of the clinical significance of change; (d) collection of follow-up data; (e)
subject attrition. Finally, careful attention needs to be paid to the instruments
used, as those will affect outcome research.

[Reference]

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[Author Affiliation]

Simona TRIP*1, Ann VERNON2, James McMAHON2

1. Oradea State University, Oradea, Romania

2. Albert Ellis Institute, New-York, USA

[Author Affiliation]

* Correspondence concerning this article should be addressed to: Dr. Simona

Popa, No. 5 Armatei Române St., Oradea, Romania; Email:
spopa@uoradea.ro

Copyright A.S.C.R. Press Mar 2007. Provided by ProQuest LLC. For permission to reuse this article, contact
Copyright Clearance Center.

COUNSELING IN SCHOOLS. A RATIONAL EMOTIVE

BEHAVIOR THERAPY (REBT) BASED
INTERVENTION - A PILOT STUDY -
From:
Cognitie, Creier, Comportament
Date:
March 1, 2008
Author:
KÃ; Opre, Adrian; ‰; ¡; llay, Ã; va; Vaida, Sebastian
More results for:
APPLICATION OF REBT AND SELF ESTEEM publication:["Cognitie Creier
Comportament"]

http://www.highbeam.com/doc/1P3-
1454504481.html
ABSTRACT

During the last five decades, Rational Emotive Behavior Therapy (REBT)
(Ellis, 1955) clearly revealed its efficiency and flexibility beyond the clinical
settings. An adapted form of the clinical model in educational environment is
the Rational Emotive Behavior Education (REBE). By its structure and
strategies, REBE strongly emphasizes the prophylactic value of the entire
paradigm. In the present pilot study we addressed the matter of such an
educational program and tested its efficiency in the Romanian high schools.
We intended to decrease students' irrationality and offer them the chance to
develop a more adaptive life philosophy, by changing the way they see and
perceive things. To reach this goal, we used an experimental design with
repeated measures. The results clearly confirm our hypotheses and sustain
the possibility of achieving significant changes in the belief systems,
emotions and behaviors, by using an REBE intervention.

KEYWORDS: rational emotive behavior education; school counseling; rational

and irrational thinking style.
REBT stands for Rational Emotive Behavior Therapy, a form of psychological
counseling first developed by Albert Ellis in the late 1950's. Its foundations
may be found in the writings of Stoics as Epicure and Epictetus. Around 500
B.C., Epictetus stated that It's not what happens to us, but how we react to it
that matters (Epictet, 2002). In other words, it is not an event that troubles
us, but our perception and the interpretation we give to that particular event.
The basic idea of this form of therapy is that we are the only ones
responsible for the way we (decide to) feel, thus suggesting that we have, to
a considerable degree, control over our thoughts (Ellis, 1979b). In a very
simple, yet effective model called the ABC, Ellis (1979a, 1985) outlined an
application for his theory, so that anyone could use it to identify and control
his/her thoughts and then change them, thus achieving more adaptive and
functional emotions, and behaviors. On the one hand, ABC stands for the first
letters of the alphabet, thus proving its simplicity and clarity, and on the
other hand, it is an abbreviation. "A" stands for the Activating Event (it refers
to any real, external event, imaginative or internal event, or even an
inference about an event) (Dryden, 2002) that might occur and trigger an
idea or a series of thoughts or beliefs. "B" stands for Beliefs, and it represents
the evaluations and interpretations of the particular event. These beliefs may
be Rational (Self Helping) or Irrational (Self Defeating). They are considered
to be rational when (i) they help us in achieving our goals, (ii) they can be
verified in reality, and (iii) they are logical. By the same token, thoughts are
considered to be irrational when they don't meet these criteria. Last but not
least, "C" stands for the consequences that might appear due to the thoughts
and beliefs that one has. These consequences are observable through the
individual's emotions or behaviors, and can be adaptive or maladaptive. An
irrational thinking pattern, once stabilized may lead to different forms of
severe intra- and inter-personal functioning (depression, anxiety,
uncontrollable anger, conflict, etc.) (Martin & Dahlen, 2004).

The basic idea of the REBT theory is that by changing one's irrational beliefs
into more flexible and rational ones, one may achieve a significant change in
the emotional and behavioral consequences, by changing them into more
adaptive ones (Davies, 2006). In a simple scheme, the ABC model can be
presented as follows (see Figure 1). For a more detailed description of the
ABC model and the REBT, see Dryden and Giuseppe (1990).

Rational Emotive Behavior Education represents a psycho-educational

preventive intervention program addressed to students. The program lies its'
foundations in the ideas of Rational Emotive Behavior Therapy.

An REBE system is characterized by a remarkable flexibility, which allows it to

be relatively easy to adapt and use in counseling diverse populations. Thus,
the program has proved its' efficiency in counseling adolescents, students,
youth in general, both overgifted students and students with special needs
(intellectual deficiency, orphans, juvenile delinquency, etc.). An REBE
program is composed of modular sequences of psychological education
intended to develop students' cognitive and behavioral competencies that
will allow them to become more productive and happier at the same time.
Back in the origins, the program was designed in the purpose of mental
health optimization through group counseling; nevertheless, properly
adapted, it can be just as efficient when used in individual therapy and
counseling with children, adolescents and adults. Analyzing the diversity and
severity of some of the problems adolescents deal with in schools, we have
to agree that implementing such efficient programs has become nowadays
more necessary than ever (Opre & David, 2006).

We started this study with the intent of seeing whether Rational Emotive
Behavior Education (REBE), derived from Rational Emotive Behavior Therapy
(REBT), could be used as an efficient educational counseling method within
the Romanian cultural norms. This is due to the fact that the current
Romanian undergraduate educational system either does not offer any viable
counseling method, or the presently used ones are not efficient enough
(Opre, 2006). Nevertheless, the REBE is a very useful method, because it can
be easily learned, taught, and then applied to virtually any student within and
outside the educational system. It is also very direct, time and cost-efficient,
for it takes a very short time to teach it, understand it, and then apply it in all
sorts of environments (Bernard & Ellis, 1983).

The first problem that we encountered after we had begun working with
students was their lack of familiarity with argumentative discussions and
polemics. Romanian students are usually used to obey to their teachers'
instructions, and reproduce what has been said (unconditionally accept
whatever the teachers tell them, without asking any explanations for their
unanswered questions). However, the reasons for using REBE go far beyond
this issue, because the irrational ideas that REBE attempts to change relate
precisely to many of the problems students have to deal with nowadays:
egocentrism, uncertainty, a global evaluation of themselves, in terms of the
achieved performance, exaggerating (awfullising) events, self-defeating
behaviors (Nucci, 2002). If we really want to help young adults overcome
their practical or emotional problems, one has to teach them how to
successfully change their dysfunctional thoughts and beliefs, thus changing
behaviors as well; otherwise, any prevention efforts are almost useless (Ellis,
2005).

In sum, we can present the purposes of REBE as it follows: helping students

become more aware of their inner dialogue by teaching them how to think
more rationally; teaching students to evaluate their own thoughts so they get
less disturbing emotions; teaching students how to use rational emotive
principles so they can more easily reach their objectives (Gonzales et al.,
2004). And, last but not least, help them achieve a more adaptive life
philosophy (Robb & Harold, 2001).

The major aim of our study is to investigate the possible benefic effects of an
REBE intervention on 11th grader Romanian students, by changing their
irrational thinking patterns into more adaptive rational ones, thus achieving a
better emotional and overall functioning. More precisely, we intended to
evaluate the possible positive consequences of a program built on the tenets
of cognitive restructuring on emotional and behavioral experiences.
Consequently, we formulated the following hypotheses: "by applying an
REBT based intervention, participants in the experimental group would
experience lower levels of irrationality than participants in the control group";
more specifically, significantly lower levels of (1) demandingness, (2)
awfullising, (3) low frustration tolerance, and (4) self-downing.

METHOD

Participants

Our study comprised an experimental and a control group, both consisting of

11th graders from two different high schools in the same city (Cluj-Napoca,
Romania). The experimental group consisted of 48 participants (24 males, 24
females), aged 17 - 19 (mean age =18.02 years, while the control group
consisted of 24 participants (11 males, 13 females), aged 17 - 19 (mean age
=18.14 years), both groups belonging to urban areas. All the participants
gave their consent for participating in this study.

Materials

In order to measure the general level of irrationality and other specific

aspects such as the level of tolerance, the level of self-esteem, etc., we
used the Attitude Beliefs Scale II (ABS II) adapted to Romanian population
(Macavei, 2002). The scale consists of 72 items (36 of them measures
rational beliefs and the other 36 irrational beliefs). The items are arranged in
a matrix consisting of three factors: (1) cognitive processes, with four levels
of irrational thinking (demandingness, awfullising, low frustration tolerance,
and self-downing), (2) content areas (approval, achievement and comfort),
and (3) items formulating rational and/or irrational thoughts. For the
intervention stage we used Vernon's Emotional Curriculum for Adolescents.

Experimental design and procedure

After the pretest phase (assessment with ABS II), we moved on to the
introductory phase, which meant presenting the students the basics of
Rational Emotive Behavior Therapy and Rational Emotive Behavior Education
(rational vs. irrational thinking styles, the ABC model, activating events,
rational vs. irrational beliefs, emotional or behavioral consequences,
functional vs. dysfunctional negative emotions, etc; for more information on
this matter, see Ellis, 1972; Ellis, 1979). After explaining and verifying their
understanding of the ABC model and the REBT foundations, we moved
further to the applications, based on several resources: Vernon's Emotional
Curriculum for Adolescents (Vernon, 1989), Bedell's Handbook for
Communication (Bedell & Lennox, 1997). The posttest (assessment with ABS
II) has been done 6 months after the intervention.

In fact, the experimental method consisted of a basic experimental design,

with repeated measures. The independent variable was the REBE program,
and the dependent variable was the level of irrationality. The intervention
itself consisted of a 6 months educational program developed in two 1 hour
meetings every week. Before implementing a selective, adapted REBE
program, we first assessed all students' basic level of irrationality, as defined
by REBT. The program was structured similar to an alternative curriculum,
inspired from Vernon's application to REBT (Vernon, 1989, 1993, 1997). We
called it Rational Emotive Behavior Education. For a more detailed example,
see Appendix 1 and 2.

RESULTS AND DISCUSSIONS

For the pre-intervention homogeneity of the two groups (1 - experimental

and 2 - control) we have conducted an independent sample t-test on the four
levels of irrationality as measured at T1, as well as on the general level of
irrationality (see Table 1).

Since there have not been found any significant differences between the
experimental (1) and control (2) groups regarding the levels of different
aspects of irrationality, we have proceeded to investigate the possible effects
of the experimental intervention by conducting a paired sample t-test
regarding the posttest results (see Table 2).

As seen, only in the case of the experimental group did the different levels of
irrationality significantly lower. Demandingness has lowered significantly in
the aftermath of the REBE intervention (t = 3.07 at p<.01), as well as Low
Frustration Tolerance (t = 3.42 at p<.00), Self-downing (t = 4.20 at p<.01),
Awfulizing (t = 6.08 at p<.01). The overall level of irrationality has as well
significantly lowered as a result of this specific type of intervention (t = 5.41
at p<.01). In the case of the control group the levels of irrationality have not
significantly changed. This means that our counseling program really had a
reasonable effect.

The literature has established cut-off points for different levels and severities
of irrationality. Thus, scores on the ABS between 0-91 represent very low
levels of irrationality; between 92-107 low levels, 108-121 moderate levels,
between 122-127 high levels and between 136-288 very high levels of
irrationality (Macavei, 2002).

Since we wanted to see who would most benefit from this specific kind of
intervention, we have a-posteriory divided our experimental group into two
subgroups: those with initial (T1) ABS scores below moderate (108) - group 1,
and those with initial (T2) ABS scores above moderate (108) - group 2.

Thus, next we have proceeded to paired samples t-test for scores obtained at
T2 (see Table 3) within the experimental group, divided depending on the
initial levels of general irrationality.

As the data suggest, the intervention was successful in both groups,

significantly reducing levels of General Irrationality, as well as the sub-
dimensions of LTF, Self-downing, and Awfulizing (p<.05), except
Demandingness, which in the case of the second group (those students who
had a higher level of initial irrationality), where this sub-dimensions has not
significantly changed (t = 1.91, at p>.05). Even if on this dimension
(Demandingness) we have not found significant changes, a future research
might highlight the reasons for such a result.

And finally, we compared whether the differences at T2 between the groups

with lower and higher levels of initial irrationality are significant or not, with
independent samples t-test (see Table 4).

As the above-mentioned table shows, even if the overall and sub-dimension

levels of irrationality in both groups have significantly lowered (see table 3),
the differences at T2 between the two groups are still significant (p <.00).
Namely, the group with lower initial level of irrationality still maintains a
significantly higher level of rationality after the intervention. This result may
suggest the fact that higher initial levels of irrationality might need longer, a
more focused, personalized and need-oriented form of intervention, might
reduce the initial level of irrationality to the post-test level of the other (1)
group.

Resuming, the main purpose of the present pilot study was to teach the
participants how to effectively identify and change their irrational thinking
patters so that they might develop a more adaptive life philosophy. Thus, the
intervention mostly targeted the cognitive level, mainly based on the
cognitive ABC model. The other two dimensions of intervention (emotional
and behavioral) will be addressed in a future research that will continue this
pilot study. Our future studies will focus other dimensions of functioning as
well, where changes in thinking patterns might have significant benefits (e.g.,
levels of affectivity, depression, school performance, interpersonal
relationships, etc.).

The change of irrational thinking patterns was achieved by implementing a

Rational Emotive Behavior Education program on a period of 6 months, on a
weekly basis, in two 1 hour meetings every week. Unlike other similar
educational programs, the effectiveness of the present one is given by the
fact that once taught and understood it can be successfully applied to
virtually any daily situation, so that participants won't just feel better but
they will also get better (Broder, 2001). Furthermore, the basic ideas
underneath this theory are so simple that they can be taught to any
individual (Weinrach et al., 2006).

CONCLUSIONS AND FUTURE DIRECTIONS

The main hypothesis concerning the decrease in the general level of

irrationality among the participants was validated, proving that a medium to
a long time intervention may be very helpful in laying the foundation for a
(more) rational life philosophy and a more adaptive life style. The other
(more) specific hypotheses were also validated, meaning that we achieved a
decrease in the level of self-downing, demandingness and awfullising, as
well as slight changes in the levels of frustration tolerance. Nevertheless, a
drastic change in the level of frustration tolerance would also be unwanted,
because it would mean a shift to the other extreme. On a continuum where at
one end we would be aggressivity and at the other end passivity,
assertiveness would be the desired attitude and behavior (Rakos, 1991). In
other terms, a very low frustration tolerance could be compared to
aggressivity and a very high frustration tolerance would equal passivity,
whereas a moderate and context specific frustration tolerance could lead to a
desired assertive behavior and attitude.

Further research is needed to identify other specific aspects to better adapt

this form of educational method to the Romanian teaching system.
Nevertheless, we consider this pilot study one of the first steps to be taken
towards achieving a positive change in the attitude of high school students
and their teachers in Romanian schools.

[Reference]

REFERENCES

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Problem-Solving Skills Training (A Cognitive-Behavioral Approach). New York:
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Problems of Childhood. New York: Plenum Press.

Broder, M. S. (2001). Dr. Albert Ellis - In His Own Words - On Success. Journal
of Rational-Emotive & Cognitive-Behavior Therapy, 2, 77-88.

Chamberlain, J. M., & Haaga, D. A. F. (2001). Unconditional Self-Acceptance

and Responses to Negative Feedback. Journal of Rational-Emotive &
Cognitive Behavior Therapy, 3, 163-176.

DeVogue, C. (1983). A Behavioral Approach to RET With Children. In M.E.

Bernard & A. Ellis (Eds.) Rational Emotive Approaches to the Problems of
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DiGiuseppe, R. (1996). The Nature of Irrational and Rational Beliefs: Progress

in Rational Emotive Behavior Therapy. Journal of Rational-Emotive &
Cognitive Behavior Therapy, 14, 5-28.

DiGiuseppe, R., (1983). The Use Of Behavior Modification To Establish

Rational Self Statements In Children, In Bernard, M.E., & Ellis, A., (Eds.).
Rational Emotive Approaches To The Problems Of Childhood, New York,
Plenum Press.

Davies, M. F. (2006). Irrational Beliefs and Unconditional Self Acceptance.

Correlational evidence linking two key features of REBT. Journal of Rational-
Emotive & Cognitive Behavior Therapy, 2, 113-126.

Dryden, W., & DiGiuseppe, R., (1990). A Primer on Rational Emotive Therapy.
Champaign, IL, Research Press.

Dryden, W., (1984). Rational and Emotional Therapy: Fundamentals and

Innovations. Beckenham, Kent, England, Croom-Helm.
Ellis, A. (1979b). The Theory Of Rational Emotive Therapy. In A. Ellis, J.M.
Whiteley (Eds.). Theoretical and Empirical Foundation of Rational Emotional
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Ellis, A. (1985c). Overcoming Resistance: Rational Emotive Therapy with

Difficult Clients. New York: Springer Publishing Company.

Ellis, A., (1971). Growth Through Reason, North Hollywood, CA Wlishire Books.

Ellis, A., (1972). Emotional Education in the Classroom: The Living School.
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Mahoney & A. Freeman (Eds.). Cognition and Psychotherapy. New York:
Plenum.

Ellis. A. (2005). The Myth of Self Esteem: How Rational Emotive Behavior
Therapy Can Change Your Life Forever. Amherst, NY: Prometheus.

Epictet (2002). Manualul si fragmente. Editura Saeculum, Bucuresti.

Gonzales, J.E., Nelson, J.R., Gutkin, T.B., Saunders, A. et al. (2004). Rational
Emotive Therapy with Children and Adolescents: A Meta Analysis. Journal of
Rational Emotive & Cognitive Behavior Therapy, 4, 222-236.

Hauck, P.A. (2001). When reason is not enough. Journal of Rational-Emotive &
Cognitive Behavior Therapy, 4, 245-257.

Macavei, B. (2002). Scala de atitudini si convingeri II (ABS II)-date preliminare

pentru populat ia de limba româna . Revista Româna de Psihoterapii
Cognitiv Comportamentale, 2, 105-122.

Martin, R.C. & Dahlen, E.R. (2004). Irrational Beliefs and the Experience and
Expression of Anger. Journal of Rational-Emotive & Cognitive-Behavior
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Nucci, C. (2002). The Rational Teacher: Rational Emotive Behavior Therapy in

Teacher Education. Journal of Rational-Emotive & Cognitive-Behavior Therapy,
1, 15-32.

Opre, A., & David, D. (2006). Dezvoltarea inteligent ei emot ionale prin
programe de educat ie rational-emotiva si comportamentala . Alexandru Ros
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Transformation? Yes, Sometimes. Journal of Rational-Emotive & Cognitive
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Vernon, A. (1993). Developmental Assessment and Intervention with Children

and Adolescents. Alexandria, VA: American Counseling Association.

Vernon, A. (1997). Counseling Children and Adolescents: Rational Emotive

Behavioral Therapy and Humanism. Journal of Humanistic Development, 35,
120-127.

Wallen, S., Di Giuseppe, R., & Dryden, W. (1992). A Practitioner' s Guide to

Rational Emotive Therapy. New York: Oxford University Press.

Weinrach, S.G., Ellis, A., MacLaren, C. & DiGiuseppe R., (2006). Rational
emotive behavior therapy successes and failures: Eight personal
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233 - 256.

Wessler, R.A., & Wessler, R.L. (1980). The Principles And Practice Of Rational
Emotive Therapy. San Francisco: Jossey Bay.

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[Author Affiliation]

Sebastian VAIDA* , Éva Kà ﾁ LLAY & Adrian OPRE

Department of Psychology, Babes-Bolyai University, Cluj-Napoca, Romania

[Author Affiliation]

* Corresponding author:

E-mail: sebastianvaida@psychology.ro

[Author Affiliation]

APPENDIX 1

The main themes in the Curricula and some title examples

MAIN THEMES

SELF ACCEPTANCE
Deleting the Past

What Matters to Me

Critics

Compliments

Success

Increase Your Chances of Success

EMOTIONS

BELIEFS AND BEHAVIORS

PROBLEM SOLVING AND DECISION MAKING

INTERPERSONAL RELATIONSHIPS

APPENDIX 2

Activity Example

INCREASE YOUR CHANCES OF SUCCESS

Objective: Developing a set of well established techniques for overcoming

failure.

Materials: Pen and paper

Time needed: 1 hour

Procedure:

Review the objectives from the former activity and

Ask the students to identify a particular situation that they failed to

Discussion

Content Questions:

How difficult was to establish a specific objective?

Personal Questions:

What can you do to increase success and minimize failure?

Suggestions (for the coordinator):

It is very important to help students establish themselves specific and
achievable objectives...

Copyright A.S.C.R. PRESS Mar 2008. Provided by ProQuest LLC. For permission to reuse this article, contact
Copyright Clearance Center.

CASE STUDY METHODOLOGY: FUNDAMENTALS

AND CRITICAL ANALYSIS
From:
Cognitie, Creier, Comportament
Date:
June 1, 2007
Author:
David, Daniel
More results for:
APPLICATION OF REBT AND SELF ESTEEM publication:["Cognitie Creier
Comportament"]

http://www.highbeam.com/doc/1P3-
1336338121.html
ABSTRACT

This article presents the fundamentals of case study methodology. After a

brief history, the presentation is based on a critical analysis to understand
the role and the place of case study methodology in scientific research. Thus,
both the advantages and the limits of this research method are discussed
and the step-by- step procedure is presented and then exemplified in a
clinical context.

KEYWORDS: case study research.

I. INTRODUCTION

1. A Brief History

The history of case study methodology as a scientific research procedure is

marked by periods of ups and downs. The earliest use of this form of
research can be related to psychophysics and medicine. In the United States,
this methodology was most closely associated with the University of Chicago.
In 1935, there was a public dispute between Columbia University
professionals, who were championing the "scientific methods" (i.e.,
experiment), and the "Chicago School" (Tellis, 1997). The outcome seemed to
be in favor of Columbia University and consequently the use of case study
methodology as a scientific research method declined (Tellis, 1997).

However, in the 1960s, researchers were becoming concerned with the

limitations of quantitative methods. Hence there was a renewed interest in
case study, although the case study methodology is not a pure qualitative or
quantitative method (Tellis, 1997).

Indeed, a quick PsycInfo based scientometric analysis confirms this history.

From 1806 to 1969 about 1319 articles dealing with "case study" and about
11171 articles dealing with "experiment" were published; the ratio is about 1
to 9. From 1960 to present, about 23151 articles dealing with "case study"
and about 46069 articles dealing with "experiment" have been published; the
ratio is about 1 to 2, which proves an increased interest in this methodology
in the psychological field.

The case study research method is defined as "an empirical inquiry that
investigates a contemporary phenomenon within its real-life context, when
the boundaries between phenomenon and context are not clearly evident,
and in which multiple sources of evidence are used" (Yin, 1984, p. 23). Thus,
case study methodology uses in-depth examination of single and/or multiple
case studies, which provides a systematic way of approaching the problem,
collecting and analyzing the data, and reporting the results.

Many proponents of case study methodology argue that it is a

comprehensive method usable for a large spectrum of problems (Yin, 1994).
On the other side, its critics argue that the study of a small number of cases
can offer no support for establishing reliability or generality of findings. Other
critics believe that the intense exposure to study of the case biases the
findings and that case study research can be use only as an exploratory tool
(see Susan, 1997).

The present article discusses the fundamentals of case study methodology.

We will not go into details, which can be found in many handbooks on this
topic. Rather, we will present the fundamentals in a critical manner so that
we can understand the condition of validity of the case study methodology in
scientific research, beyond the positions of its fervent supporters and critics.

2. When to use case study?

The aim of scientific research is to produce knowledge that can be used to

solve various problems, either theoretical or practical. Therefore, the use of
case study methodology as a scientific research tool will be determined by
the type of knowledge needed to solve a target problem. More precisely, a
case analysis methodology is rigorous and acceptable in scientific research
provided it meets the aims of the research. A review of the literature
suggests the following conditions in which case study methodology is
indicated in research.

(1) Case study methodology can be used as an exploratory methodology

helping to generate scientific theories. A scientific theory is an organized
system of propositions embedding knowledge. Some of these theories have
a descriptive role, while others have an explanatory and predictive role. As an
organized system of propositions, a theory also has a role in organizing our
knowledge about various phenomena.
(2) Case study methodology can be used to test a scientific theory. This is a
heated discussion in epistemology. As we have shown above, many critics of
the case study methodology think that the study of a small number of cases
cannot offer a basis for the reliability and generality of findings and thus, in
testing a theory.

The proponents of case study methodology (e.g., Yin, 1994) defend it by

arguing that (1) the generalization of results is made to the theory not to
populations; and (2) case study methodology provides generality by
replication rather than sampling logic. Typically, a theory is tested based on
two procedures: verification (i.e., trying to find examples congruent with its
predictions) and falsification (i.e., trying to find counter-examples to its
predictions). In our opinion, case study methodology can be used to test a
theory in the second case only. According to Karl Popper,
falsification/falsifiability is the most rigorous method to test a scientific
theory. Falsifiability implies that for an assertion to be falsifiable it must be
logically possible to make an observation that would show the assertion to be
false. Thus, if only one observation does not fit with the assertion, it will
invalidate the theory, which should be either dismissed or revised. Case study
methodology is very much appropriate to rigorously identifying and analyzing
such crucial observations. Having said that, we remind our readers the Quine-
Duhem thesis, which argues that each theory is tested in conjunction with a
number of auxiliary hypotheses. If a prediction is falsified, this could mean
that there is something wrong with the conjunction between the theory and
the auxiliary hypotheses rather than the theory is false (Greenwood, 1989).
Thus, Quine argues that a scientist is never forced to reject a theory in the
face of recalcitrant data; the theory can be preserved by the modification of
the auxiliary hypotheses (Greenwood, 1989). In the case of verification,
replication (e.g., by including multiple case studies) provides indeed support
for generality but because the cases are not in the same framework (i.e., the
same context and time) as in sampling logics, the probability of error is
increased. To make a long story short, in theory, case study methodology can
be used to test a theory by following a falsification rather than a verification
logic; however, in practice it is hard to meet this condition for the reason
briefly discussed above.

(1) Case study methodology can be used to exemplify an already validated

theory. This is very important for didactical reasons and for reinforcing an
already validated theory because this condition can also be conceptualized as
an effort to further test the theory following the falsification logic described
above.

(2) Case study methodology should be involved in research when knowledge

is intended to be used and refers to the investigated case studies only.
Indeed, case study methodology uses in-depth examination of single and/or
multiple case studies, and thus, it provides a systematic way of rigorously
understanding these cases.

(3) When no other cases are available (i.e., critical and/or unusual cases), the
researcher is limited to case study methodology (i.e., single-case design). If
the objective is similar to that described at point 4, case study should be the
choice research methodology.

3. When to avoid using case study?

Case study is not useful in testing a theory based on verification, and then
arguing that the theory is validated. Generally, the choice for or against case
study methodology depends on the problem we have to solve. If the problem
implies knowledge based on sampling logics, case study methodology should
be avoided.

4. Case Study Step-by-Step

There are several components of a good case analysis methodology:

a. The research should start with the problem - the study question. The
problem can be defined as a discrepancy between an initial state (what he
have) and a final state (what we want to have). A rigorous problem will define
precisely the initial state and will specify clearly the objectives. A serious
problem is one in which the discrepancy between the initial and final states is
approachable by current methodology. For example, if my proposed final
state is to eliminate all mental disorders in the next two years, this will not be
considered a serious problem considering current knowledge in clinical
psychology and medicine.

b. The objectives and/or the hypotheses should be made clear (if they exist).

c. The next step involves defining the unit of analysis and than data
collection. It must be made clear that data collection can be guided by either
quantitative and/or qualitative methods. Data can come for various sources
and depending on the problem and objectives, it can be collected
qualitatively (e.g., by interview) and/or quantitatively (e.g., numerically).

d. Once collected, the data is analyzed quantitatively and/or qualitatively. If it

was collected qualitatively (e.g., by interview) it can be analyzed either
qualitatively (e.g., thematic analysis) or quantitatively (e.g., frequency). If
data was collected quantitatively (numerical) it can be analyzed
quantitatively, either inferentially or descriptively.

e. In the next step, logic is used to link our results to our objectives and/or
hypotheses. This is where people who use case study methodology make
most mistakes (e.g., generalize when it is not the case). Therefore, it is
fundamental to binocularly integrate the logics and the design of the study to
avoid such errors.

f. Finally, based on the aspects discussed at point "e", conclusions and

discussions should interpret the findings in the particular context and in the
larger context of the scientific literature on the topic.

Having presented the fundamentals of case study methodology let us now

try to exemplify its use in clinical practice. Based on the above presentation,
we use case study methodology to: (1) exemplify an already validated theory
(with didactical purposes) and (2) to further test this theory based on the
falsification principle; more precisely, if the theory is to be invalidated we
expect no success in the treatment of this clinical case.

II. APPLICATIONS

Case Study in Research (adapted after David & McMahon: "Clinical strategies
in cognitive behavioral therapy; a case analysis" published in the Romanian
Journal of Cognitive and Behavioral Psychotherapies, vol. 1, no. 1, September
2001, pp. 71-86; see also David, 2003; David et al., 2004; David, 2006a;
2006b). The case of "Dana" is a classic one in the Romanian clinical
literature; this is why it is presented based on its previous publications,
although the context is new (i.e., case study methodology).

1. The Problem

1.1. Introduction

Many people find the distinction among "Behavior Therapy (BT)", "Cognitive
Therapy (CT)", "Cognitive Behavior Modification (CBM)", and "Rational
Emotive Behavior Therapy (REBT)" confused and confusing (Dobson, 2001;
Lazarus, personal communication). We believe that the time has come to stop
elaborating on details regarding the various schools and systems of cognitive
behavior therapy/therapies (CBT), and (1) to focus on the science and theory
of cognitive behavior therapy; (2) to discuss treatments of choice for specific
conditions; (3) to focus on what is and what is not empirically supported; and
(4) to develop really good manuals so that experimentally oriented clinicians
can endeavor to test, repudiate or replicate particular claims and findings. We
think that all these goals can be accomplished under the umbrella of
cognitive science. Cognitive science attempts to understand the basic
mechanisms governing human mind, basic mechanisms that are important in
understanding behavior studies by other clinical and social sciences.
Cognitive science studies the foundation on which many other social and
clinical/psychological sciences stand (Anderson, 1990).

We believe that cognitive science could be a setting for theoretical

integration within CBT (see also, Ingram & Siegel, 2001). A well-integrated
CBT should easily support different therapeutic strategies in a coherent
theoretical framework. In my opinion, even if there is a strong premise for a
coherent theoretical framework in CBT, an artificial division is maintained
because of the confusion among assumptions/paradigms, theories/models,
and clinical practice debates in CBT. A paradigm is a general pool of
constructs and assumptions for understanding a domain, but it is not tightly
enough organized to represent a predictive theory (Anderson, 1983).
Although at this level we could find incompatible differences among different
schools of CBT, we do not have the tools that would allow us decide which
one is right and which one is wrong. The paradigm is not a level of
conceptualization for disputation or integration. A theory provides a
predictive deductive system, while a model is the application of the theory
to a specific phenomenon. It is at this level of theories and models that we
argue for a coherent science of CBT, based on empirical evidence. Practice
refers to the application of therapeutic strategies and techniques.
Strategies and techniques should be numerous, different and theory driven
so we can check for their efficacy under different conditions.

Our basic argument is that CBT should be driven by cognitive science theory
in clinical research and theory, case conceptualization, and empirically
validated treatments of choice for specific conditions. In the next section of
this article, we discuss (1) some brief considerations on cognitive science and
the theory of emotions, with implications for theoretical integration within
CBT; (2) a case conceptualization based on the theoretical considerations;
and (3) a CT strategy and an elegant REBT strategy to change the target
cognitions in order to change the emotional difficulties. The inelegant REBT
(see Ellis, 1994 for details about the distinction between elegant and
inelegant REBT) seems to be similar with CT so that such a comparison
becomes redundant. Pros and Cons for each strategy are briefly mentioned.

1.2. Cognitive science and emotional problems; A brief presentation (see also
David, 2003; David et al., 2004)

Any analysis of cognitions should take into account a fundamental distinction

between "knowing" and "appraising" (Wessler, 1982). Abelson and Rosenberg
(1958) use the term "hot" and "cold" cognitions to make the distinction
between appraisal (hot) and knowing (cold). According to Lazarus and Smith
(1988) cold cognitions refer to how people develop representations of the
relevant circumstances (i.e., about activating events). Such circumstances
are often analyzed in terms of surface cognitions (easy to access consciously)
and deep cognitions (more difficult to access consciously). Surface cognitions
refer for example to inferences and attributions, while deep cognitions refer
to schemas and other meaning-based representations (for details see
Anderson, 1990; Lazarus, 1991). Hot cognitions refer to how people further
process cold cognitions. They can be more or less abstract (e.g., "It is awful
when my wife does not listen to me" versus "It is awful when people do not
listen to me"). The terms appraisal or evaluative (hot) cognitions are used to
define the processing of cold cognitions and their relevance for personal well-
being (for details see Ellis, 1994; Lazarus, 1991). Consequently, during a
specific activating event, there are different possibilities regarding the
relationship between cold and hot cognitions related to the activating event:

(1) distorted representations of the activating event/negatively appraised;

(2) non-distorted representation/negatively appraised;

(3) distorted representations/non-negatively appraised;

(4) non-distorted representations/non-negatively appraised.

According to Lazarus (1991) and the appraisal theory of emotions, although

cold cognitions contribute to appraisal, only appraisal results in emotions.
Some previous influential research programs showed that cold cognitions
(i.e., attributions, inferences) were strongly related to emotions (e.g.,
Schachter & Singer, 1962; Weiner, 1985). However, according to more recent
developments in cognitive psychology, cold cognitions are relevant to
emotions because they contribute to the data we evaluate with respect to
adaptive significance. Now it is generally accepted that as long as the cold
cognitions remain unevaluated, they are not sufficient to produce emotions
(Lazarus & Smith, 1988; Lazarus, 1991; Smith, Haynes, Lazarus, & Pope,
1993).

Following the previous distinction between hot and cold cognitions, according
to the appraisal theory of emotions, emotional problems will only appear in
cases 1 (distorted representation/negatively appraised) and 2 (non-distorted
representation / negatively appraised). In case 1 (distorted representation /
negatively appraised), if one changes the distorted representations (e.g., "He
hates me") into an accurate one (e.g., "He does not hate me"), one may end
up changing the negative emotion (anxiety) into a positive one (happiness).
However, the individual may still be prone to emotional problems because
the tendency to make negative appraisals (e.g., "It is awful that he hates
me") is still present. If one changes the negative appraisal (e.g., "It is awful
that he hates me") into a less personally relevant one (e.g., "It is bad that he
hates me but I can stand it"), it is probable to change the dysfunctional
emotion (anxiety) into a functional but still negative one (concern; for the
distinction between functional and dysfunctional emotions see Ellis, 1994). A
strategy that will change both distorted representation and negative
appraisal seems to be a better choice. In case 2 (non-distorted
representation/negatively appraised), the choice seems to be the change of
negative appraisal that would generate a positive (happiness) or negative
(concern) functional emotion. Another possibility is to change a non-distorted
representation (e.g., "He really hates me") into a positively distorted one (i.e.,
positive illusion: "His negative comments are a way of communicating that
he considers me a strong and reasonable person"). However, as in the first
case, in the second situation we may change both representation and
negative appraisal.

We believe that a clinical case conceptualization based on cognitive science

should take into account both processes: cold cognitions and hot cognitions.
Although this idea is generally accepted in the clinical literature, Wessler and
Wessler (1980) note that in CBT we do not always clearly differentiate cold
from hot cognitions. Moreover, this distinction is opaque in practice (Wessler,
1982). For example, in REBT both cold cognitions and hot cognitions are
mentioned, but the clinical conceptualization is focused on evaluative/hot
cognitions (irrational beliefs). Cognitive therapy focuses mainly on cold
cognitions, both of surface and deeper level. Even if Beck (1976) argues the
certain schemata involve evaluations and that schemata are similar in
breadth to Ellis's irrational beliefs (DeRubeis, Tang, & Beck, 2001), CT case
conceptualization and interventions are more focused on cold cognitions
(e.g., inferences, attributions, automatic thoughts) rather than on evaluative
beliefs. Generally, CT focuses more on cold cognitions, that is, facts that can
be empirically validated, while REBT focuses more on the hot cognitions, that
is, evaluative cognitions (Dobson, 2001). Because clinical intervention is
driven by case conceptualization often not involving a clear distinction
between hot and cold cognitions, many artificial misunderstandings appear.
We believe that case conceptualization should be theory driven, and that it
should take into account both cold and hot cognitions. This way, CT and
REBT techniques could be seen as different therapeutic strategies in a
coherent theoretical and clinical framework. Within this framework, the
pseudo-problem of CT versus REBT can be replaced by a discussion on
strategies of choice to change different types of cognitions.

2. Clinical case; History, clinical conceptualizations and treatment

2.1. Case History

Dana is a 28 years-old physician, mother of one, who lives with her husband,
and who has been working full-time as a fellow in gastro-enterology for the
past 3 years.

Chief Complaint. Dana sought psychological treatment for panic attacks and
generalized anxiety at the end of and the beginning of 2000 (18 sessions).
Two months before treatment she had had three panic attacks and feared
having another one. She also reported: "Since about 1991, I have been
feeling nervous and excessively anxious about my life (e.g., "my future job as
a physician"), my relationships (e.g., "with colleagues and my husband") and
my significant activities (e.g., "my school performance, my doctorate"), but
right now I am much more concerned about the recent panic attacks".

History of Present Illness. In 1991, Dana moved away from home, far from
her overprotective parents, to study medicine at a prestigious university.
Starting then she began feeling helpless and she reported attacks of
excessive anxiety and "worry about everything" (emotional symptoms).
These emotional states were often associated with muscular tension, feelings
of weakness, fatigue, and sleep disturbance (physiological symptoms). She
always found it difficult to control these physical symptoms and,
consequently, she started avoiding activities that required physical effort
(behavior symptoms). She thought that her symptoms would affect her
performance at work and her value as a competent human being (cognitive
symptoms); consequently, she often felt helpless, with low self-esteem. Her
GP and then a psychiatrist prescribed her Buspar (Buspirona) (in 1993). After
several months of medical treatment, she gave it up, as it had reduced
symptoms less than she expected. The first panic attack occurred while she
was preparing for her doctoral exam about two months before our first
meeting (1999). About one month later she had another attack. At the time
of the second attack she was at home cleaning her apartment. The third
panic attack occurred just one week before our first meeting, while she was
home alone, preparing a paper for a scientific congress. Her panic symptoms
included the following: Emotional symptoms: intense fear of loosing control,
helplessness and discomfort; Cognitive symptoms: believing that she was
going to die, had heart problems, and that she was going to faint and
collapse; Behavioral symptoms: avoiding physical effort and looking for safe
places in case she fainted; Physiological symptoms: palpitations, trembling,
and chest pains. She consulted a psychiatrist regarding these symptoms, and
was prescribed XANAX just two months before our first meeting.

The major stressors in Dana's life were mainly social. She was an
overprotected child, and being far from home and from the protection of her
parents during training in medical school was the first major stressor that
might have precipitated her generalized anxiety (1991). Moreover, before
getting married (she got married in1998), Dana had hoped that her husband
would be a real support for her. She believed that he could help her to
overcome her anxiety and her "worries about everything". Unfortunately, her
husband's job was highly demanding. He was an assistant professor and a
researcher often working hard late at nights and on weekends. He was not
very involved in the household and in their child's education (the birth of
Dana's son was another stressor and opportunity for her to worry about:
"Considering that I am so busy, how will I have enough time for my son?").
Consequently, she felt overwhelmed by her life as wife, mother, physician,
and student, doing her full-time job as physician, cleaning the apartment,
cooking, taking care of her son, and preparing for her exams doctoral exams.
These were the conditions in which her first panic attacks developed (1999).

Personal and Social History. Dana was an only child. She described her father
as very rigid, controlling and concerned with the future of his daughter.
Because of his authoritative attitude she had been afraid to argue with him
or ask something from him (the same thing is true even now as an adult). She
described her mother as a warm person, highly concerned with the education
and the future of her daughter. Dana remembered that during kindergarten,
primary and secondary school she had been overprotected by her parents but
that she had not liked that attitude at all. For example, every morning they
left her at school and in the afternoon they picked her up. Because of this,
she had no opportunity to have friends and/or be with her colleagues. She
described herself as a girl (and now a woman) with very poor social and
assertiveness skills both at home and in other social situations. During high
school she started preparation for medical school. Both parents wanted her to
attend medical school. They allowed her to have a boyfriend (the relationship
was not very intense); however, they were only allowed to meet at her home
or go out for several hours in the afternoon. After starting medical school
(1991), Dana had to move to another town. During the first year (she was 18)
her parents visited regularly. They did not want her to live in a dorm with her
colleagues, so they rented an apartment where she could learn without being
disturbed by others. During her first year in medical school she started
experiencing intense signs of generalized anxiety and some symptoms of
subclinical depression. She felt alone, helpless, and started to worry about
everything (but not about the separation from her parents - this was one of
the reasons why we did not consider a diagnosis of separation anxiety!).
During her second year of study (1993) she decided to see a general
practitioner and a psychiatrist who prescribed her Buspar (Buspirona). After
several months she gave up treatment because the symptoms of generalized
anxiety persisted. Despite these symptoms she graduated medical school
successfully in 1997 and started working as a fellow in gastro-enterology. She
met her husband around the same. She described him as very bright, strong
and mature man, 15 years older than she was. They fell in love and got
married in 1998. They live in the same town where she graduated medical
school. After one year of marriage their son was born. In 1998 she started a
doctoral program in medicine. During their second year of marriage (1999)
she experienced her first panic attack. I (DD) met her in 1999 after she had
experienced three panic attacks. Beside psychotherapy, Dana took
medication (XANAX) prescribed by her psychiatrist.

Medical history. Dana had no medical problems which could influenced her
psychological functioning or the treatment process.

Mental Status Check. The patient was fully oriented with an anxious mood.

DSM IV Diagnoses. Axis I: Panic disorder without agoraphobia and generalized

anxiety disorder (subclinical depression - the patient has some symptoms of
depression but she does not meet the full criteria for any depressive
disorder); Axis II: None. The patient does have some dependent personality
traits. However, a careful analysis has revealed that dependent behaviors
seem to be related to the anxiety disorders and that an independent
diagnosis of dependent personality disorder is not justified; Axis III: None;
Axis IV: Inadequate social support, overwhelmed by life circumstances (e.g.,
housing problems, demanding work conditions, educational solicitations);
Axis V: GAF 60 (current -1999-). Best during the past year - 70.

2.2. Case formulation/conceptualization; A cognitive therapy perspective (by

Dr. Daniel David)

A. Precipitants. Dana's separation from her overprotective parents, her lack

of social and assertive skills, and her immersion in a completely new context
(e.g., new town, new colleagues, new requirements) probably precipitated
and then maintained the generalized anxiety and the subclinical depression.
The panic disorder may have been precipitated by lack of support from her
husband and because she felt overwhelmed by her duties. She expected her
husband to support her emotionally. In fact, after getting married, she felt
overwhelmed, and that she had more duties than before. This is when she
experienced her first panic attack.

B. Cross-Sectional of Current Cognitions and Behaviors. Typical of Dana's

current problematic situation was the one related to her first panic attack.
While preparing for her doctoral exam in her room, she had the following
automatic thought: "I will not be able to prepare properly over the next few
days because nobody helps me with my other duties and nobody can give me
more time to prepare for the exam" (surface cold cognition: automatic
thoughts). Emotionally she felt anxious, stopped reading, and jumped out of
her chair. Then she started to experience shortness of breath, chest pain,
palpitations and uncontrollable trembling. At that moment she had another
automatic thought/catastrophic interpretation: "I am sick and I am having a
heart attack" (surface cold cognition: automatic thoughts). Her symptoms
became more intense (panic about panic-secondary emotion) and the world
seemed strange and unreal. Emotionally she felt fear and intense discomfort.
She went out of the room and tried to reach the bathroom to wash her face
with cold water. A second typical situation is illustrated by the second panic
attack. While she was cleaning her apartment she started having palpitations.
Her automatic thought/catastrophic interpretation was: "Not again. I will die
and nobody will take care of my son" (surface cold cognition: automatic
thoughts). Over the next few minutes she developed another panic attack
with palpitations, chest pain and trembling. She tried to reach an armchair (in
case she fainted) and the phone in order to call her husband (she did not call
him). A third situation occurred when she was preparing a paper for a
scientific congress. She thought: "I don't have enough time to prepare a very
good paper. Nobody helps me have more time" (surface cold cognition:
automatic thought). She started having palpitations and almost immediately
thought/made a catastrophic interpretation: "Oh, my God, I am really sick. I
am going to faint and collapse" (surface cognition: automatic thought). Within
a few minutes, she experienced the third panic attack but this time the fear
of losing control or going crazy was stronger. She went into the living room to
be closer to the phone and she sat down in the armchair trying to relax.
Despite assurance by her GP that nothing was wrong with her physical
health, Dana still related her panic and anxiety attacks to an undiagnosed
physical illness. Even though she was open to referral for psychotherapy, she
was not very open to a psychological conceptualization of her problems.

C. Longitudinal View of Cognitions and Behaviors. Dana grew up with very

protective parents. He job was to learn well. Her parents took care of
everything for her. She had plenty of time to organize learning activities.
Consequently, she was a very good student. Three core beliefs (deep cold
cognitions) developed in connection with her past experiences. The first core
belief (schema) refers to competence: "doing everything at high standards".
This deep cold cognition is often appraised: "I have to do everything at high
standards otherwise I am inadequate, unlovable and weak" (hot cognition).
The second core belief refers to both responsibility and control: "If the others
do not support me, I am not able to focus on, to control and succeed in
important things in my life". This deep cold cognition is further appraised:
"Significant people in my life must help me control my environment in order
for me to focus on and to reach my important objectives. If they don't, it is
awful and I can not stand it" (hot cognition). The third core belief is related to
comfort and control and it seems to be linked to secondary emotions (i.e.,
panic about the panic): "If I am helpless and cannot control myself, I and the
others will suffer". It is negatively appraised: "I have to be in control
otherwise it is awful and I cannot stand it" (hot cognition).

D. Strengths and assets. Dana is a bright person with a good physical health.
She loves medicine and she is very disciplined. She wants the best for her
and her family and consequently, no effort is to high to attain these goals.
She has lived with generalized anxiety for almost 7 years. The coping
mechanisms she employed during these years were: avoiding problems,
avoiding physical exercise and studying hard.

E. Working hypothesis. Dana experienced generalized anxiety because her

core beliefs made her interpret a wide range of situations as threatening. Her
separation from her parents and her immersion in a completely new
environment (e.g., new town, new colleagues, higher requirements than in
high-school) probably precipitated the generalized anxiety and the subclinical
depression by activating these core beliefs. Moreover, her lack of
assertiveness and social skills (e.g., dependent personality characteristics)
could have amplified and contributed to anxious and depressive symptoms.
Later, by corroborating this background of generalized anxiety with (1) the
pressures in her life after marriage and (2) the frustrations concerning the
expected support from her husband, the panic attacks developed. Panic
attacks were stimulated by her catastrophic interpretations, which often
generated panic about the panic.

2.3. Treatment plan; A cognitive therapy perspective (by Dr. Daniel David)

A. Problems list: (1) Dana's panic attacks; (2) general feeling of worry about
everything (generalized anxiety and subclinical depression); (3) relationship
with her husband concerning the support he might offer to her (4) low
selfesteem and social and assertiveness skills.

B. Treatment goals: (1) to reduce panic attacks (including panic about panic);
(2) to reduce negative distorted thinking with impact on generalized anxiety
and subclinical depression; (3) to build assertiveness and problem solving
skills in order to improve the relationship with her husband and her ability of
solving practical problem; (4) increase social skills with impact on her
dependent personality traits.

C. Treatment plan. The treatment plan was to first reduce Dana's panic
attacks (including panic about panic) and then her generalized anxiety and
subclinical depression. We also planned to work on her assertiveness, self-
esteem, and social skills. Finally, some practical problems were approached
and a relapse prevention program was introduced.

For panic attacks we used a treatment package involving: (1) cognitive

restructuring techniques (Clark, 1995) to reduce catastrophic interpretations
(automatic thoughts) and (2) hyperventilation/controlled breathing
techniques (Ost, 1987) to explain (partially) and control panic symptoms. A
distraction technique was also used at the beginning of the intervention with
both didactical (cognition versus emotion) and therapeutic (quickly help
symptom management) role. The panic package was then adapted for
generalized anxiety and subclinical depression, and it consisted of: (1)
cognitive restructuring techniques (Beck, 1976; Clark, 1995) to change
automatic thoughts and core beliefs and (2) relaxation techniques (Ost, 1987)
to reduce the chronic arousal. We also focused on changing (at different
levels of abstractions) the evaluative cognitions associated with the core
beliefs. In order to enhance assertiveness and social skills we used
assertiveness training, social and problem solving skills training, to help her
become more self-confident and less dependent. The treatment package was
implemented as follows.

1. The patient was taught a distraction technique for panic attacks (e.g., to
describe in detail all the objects in the room). This technique: (a) would
counter Dana's belief that she had no control over her anxiety; (b) be a useful
symptom management technique when it was difficult to challenge automatic
thoughts; and (c) be a potent demonstration of the cognitive model of
anxiety to which Dana was initially quite reluctant. She was then introduced
to voluntary hyperventilation technique. This was useful in modifying her
catastrophic interpretations of the bodily sensations she experienced during
panic attack. Controlled breathing was also introduced with the purpose of
reducing hyperventilation.

2. The patient was taught standard cognitive restructuring and behavioral

techniques for her automatic thoughts, catastrophic interpretations, and later
for her core beliefs. We also focused on changing hot cognitions by working
at different levels of abstraction. These techniques allowed Dana to
understand maladaptive thoughts and assumptions and thus significantly
reduced anxious and panic symptoms, subclinical depression, and some of
the dependent traits.

3. Dana was taught a relaxation technique and a controlled breathing

technique. The relaxation technique was expected to mainly impact on
generalized anxiety, as it reduces chronic arousal.

4. Assertiveness training and social and problem-solving skills were

introduced in order to improve her interpersonal relationships (particularly
with her husband) and problem solving abilities. These interventions would
also help her be less dependent.

5. A relapse prevention program was introduced at the end of the treatment.

Obstacles. As she was trained as a physician in the bio-medical model, it was

hard to convince Dana about the relationship between cognition and emotion
using a conventional approach. Thus, the rationale of treatment (e.g.,
relationship between cognition and panic attacks) was not forced upon the
patient. Instead, more techniques were used than with other patients to
illustrate this relationship: (1) bibliotherapy - books on psychosomatic
medicine, cognition, and emotion; (2) more examples including literature on
the experiments (cognition-emotion relationship) of Schachter and Singer
(1962). At the end of this educational program the patient was very surprised
about the influence of cognition over emotion and was eager to introduce
these ideas not only in our work but also in her work as gastro-enterologist.

Outcome. Dana's therapy extended over 18 sessions. Six months after the
end of therapy, Dana had no recurrence of panic attacks or symptoms of
subclinical depression. However, some symptoms of generalized anxiety
persisted but they did not meet the DSM IV criteria for generalized anxiety
disorder. Dana's assertiveness and social skills improved significantly and had
a positive impact on her relationships (including with husband and parents)
and on the reduction of dependent personality characteristics. All these
results are operationalized in a single case experiment design: multiple
baselines across symptoms.

2.4. Case Formulation; An REBT perspective (by Dr. James McMahon)

This married medical student, 28, mother of a child, tried medical/psychiatric
interventions without success at first, and, with the realization that she would
become addicted to increased use of medication to ward off anxiety
symptoms, tried psychological intervention latter. When her thoughts turned
to feelings of worry and worthlessness, she panicked and was unable to
believe in herself and her ability to manage herself. These beliefs were put
into place later in life; while she was able to achieve academically through
her life, because she was overprotected, she had few skills that enabled her
to believe in her own general self management. Escaping from rigid
protection, she went on her own into an apartment and she eventually
married. She demanded (demandigness - DEM) that her husband take the
place of her parents to some extent by providing her with support and rules.
He did not. Instead, he cooperated with her in baby making, he went about
his career and he left Dana with her own career as well as with house and
childcare responsibilities. To deal with panic and anxiety, it was
conceptualized that Dana has superior intelligence, that she could make
logical, empirical and pragmatic distinctions/disputations, and that she would
work within rules to change her dependency. She was willing to read and
engage a given/take process of therapy, and she was willing to keep a log of
behavior. A careful analysis revealed many types of cognitive distortions,
both surface and deep (see Dr. David's analysis) and a group of irrational
beliefs (evaluative cognitions) like: (1) demandigness - DEM (e.g., "I have to
do everything at high standards; the others have to help me", etc.); (2)
awfulizing - AWF (e.g., "If I am not in control it is awful"); (3) low-frustration
tolerance -LFT (e.g., "I cannot stand it") and selfdowning - SD (e.g., "I am
weak and inadequate").

2.5. The treatment plan; An REBT strategy (by Dr. James McMahon).

Treatment was conceptually divided into four components: (1) immediate

management of panic through ego anxiety and discomfort anxiety theory
and practice; (2) unconditional self and other acceptance with impact on
generalized anxiety, sublinical depression and dependent characteristics; (3)
practice against regression through logical, empirical, and pragmatic
disputation as well as recognition of irrational beliefs; (4) solving some
practical problems. These four distinctions integrated, it was conceptualized
that Dana could (a) be happy as a person who liked herself, (b) become self-
managed rather than reach out to others to provide management for her, and
(c) that she could work against regression to irrational beliefs with simple
reading and practice. In addition to cognitive restructuring of irrational
beliefs, it was suggested that Dana engage philosophical change by
distinguishing who she was from what roles she played. A distinction between
practical and emotional problems was made and the patient realized the
usefulness of focusing first on the emotional problems and then on the
practical problem. The emotional problems were separated into primary
emotional problems (panic and generalized anxiety) and secondary emotional
problem (panic about panic).

An REBT treatment regimen was put into place, the process of intervention
was commented upon and acceptable to both patient and therapist. Several
issues were emphasized to her namely, that the idea was to be better not get
better, that two primary aspects on the neurotic continuum of thinking-
feeling were her tendency to exaggerate (awfulizing) and to avoid negative
emotions, thereby giving her temporary comfort but long-term misery (low
frustration tolerance). Also it was discussed with Dana how her problems
seemed to be related to demandigness oriented to her own person (e.g., "I
have to do everything at high standards") and others (e.g., "Others have to
help me"). If these demands are not attained, then she moves into self-
downing (e.g., I am weak), awfulizing (e.g., "It is awful") and low frustration
tolerance (e.g., "I cannot stand it"). Session 2-4 went to the heart of panic.
Checked was the secondary problem (panic about panic) and the irrational
beliefs involved (e.g., "I have to be in control otherwise it is awful and I
cannot stand it"; DEM, AWF and LFT). The primary emotional problem was
then focused upon (where we identified others DEM, AWF, LFT and SD).
Session 5-7 stressed self-worth issues related to generalized anxiety and
subclinical depression (e.g., stubborn refusal to judge herself, examining her
roles and how to judge them through the who/what process, rational-emotive
imagery in which she perceived herself to be in control of her own life and
that she was in charge, and disputation of other irrational beliefs). Sessions
8-12 involved further restructuring of IBs into adaptive alternatives (at
different levels of abstraction) and how to distinguish beliefs from feelings
about beliefs. She kept a log of the type of empirical, logical and pragmatic
disputations. Session 13-18 involved dealing with issues of dependency
throughout her life, looking for alternative conceptions. Some practical
problems were approached, and revisiting panic and anxiety situations was
undertaken to preclude regression.

Outcomes. Dana reported in the last session that she was free of panic
attacks, that she could distinguish rational from irrational beliefs, and that
she generally felt happy and liked herself. Regarding her own goals, she
indicated that she was generally happy but busy with her family and work,
that she judged that she could head off panic attacks in the future, and that
she was assertively negotiating home duties with her husband. The patient
and the therapist judged that she achieved good results therapeutically and
as a person.

2.6. Discussion

2.6.1. Comment upon the cognitive therapy strategy (by Dr. James
McMahon).

The work of Dr. Daniel David was generally masterful: good diagnosis, good
interventions, and the goals were attained. He used all available CBT
techniques that were appropriate by distinguishing automatic thoughts vs.
core beliefs vs. evaluative cognitions. However, I would mention that the
distinction between core beliefs (cold cognitions) and evaluative cognitions
(hot cognitions) is not always clear in cognitive therapy, although here, Dr.
David made it very clear. Also, many cognitive therapists prefer to work only
at the level of distorted cold cognitions, both surface and deep, rather than
at both cold cognitions and evaluative beliefs. In that case, the patients may
feel better but not get better. For example, they may feel better because the
activating events (e.g., "It is not true that she laughs at me") are not
dangerous, but the individual still may be prone to emotional problems
because the tendency to make negative appraisals (e.g., "It is awful when she
laughs at me") of activating events incongruent with their goals (e.g., "She
really laugh at me") is still present. However, here, Dr. David approached
correctly both types of cognitions. If there were one negative aspect, that
would be that therapy did not get to the person. Rather, therapy dealt with
symptoms, and then their causes and cure. While achieving personhood in CT
can be inferred, it can only be inferred as one of the several schemas since
the theory purports to be empirical and so deals with piece-by-piece
examples of pathology. Contradistinction, REBT theory clearly tries to
achieve fundamental philosophical change and so is person driven.

2.6.2. Comments upon REBT's strategy (by Dr. Daniel David).

I think that Dr. McMahon's elegant REBT is really elegant: great clinical
approach! Unlike me, Dr. McMahon attacked evaluative cognitions directly. I
myself would approach evaluative cognitions, but after a careful challenging
of automatic thoughts and core beliefs. My general criticism to Dr. McMahon's
approach would be that by directly changing evaluative cognitions and
assuming that distortions are real (e.g., "Let us suppose that you are indeed
not able to work at high standards; How does this make you weak and
inadequate as a person?" or "How is this awful?", etc.) one may change a
dysfunctional emotion (anxiety) into a negative functional emotion (concern)
because automatic thoughts (e.g., "I will not be able to prepare my
presentation") and deep cold cognitions are not directly disputed in the
elegant REBT. I know that Dr. McMahon might suggest that by changing
evaluations one indirectly changes distortions too, and indeed, one may
invoke some corpus of research which supports this hypothesis (Dryden,
Ferguson, & Clark, 1989 but see Bond & Dryden, 2001). However, sometimes
distortions may gain functional autonomy from the evaluative cognitions (see
Allport's concept of "functional autonomy"); in this case the change of
evaluative cognitions might not be accompanied by a change in the
distortions. Consequently, the client may feel better (e.g., "concern" rather
than "anxious") but not achieve the best results (e.g., "relaxed", "calm" or
even "happy"). On the other hand, as Ellis repeatedly mentions, (Ellis, 1994),
not all patients may benefit directly from elegant REBT. However, in our case
the patient seems to be in a positive emotional state and thus, Dr. McMahon's
direct disputation of IBs also seemed to change cognitive distortions (i.e.,
elegant REBT). If that had not happen, I suppose that Dr. McMahon would
have forcefully disputed the distortions too (i.e., inelegant REBT). The
difference between our approaches seems to be in terms of strategy. I
started with automatic thought, core beliefs and then evaluative cognitions.
With bright clients, Dr. McMahon seems to prefer starting with evaluative
cognitions and then maybe working on distortions, if necessary (I know that if
the change of irrational beliefs was not accompanied by a change in
distorted cold cognitions, Dr. McMahon would directly examine automatic
thoughts and other distortions - personal communication). I would like to see
some research evaluating concurrently these two different cognitive
strategies. I assume that their efficacy may differ depending on the clinical
condition (e.g., the type of psychopathology, the type of client).

III. DISCUSSIONS

After a short history, this paper briefly and critically presented the
fundamentals of case study methodology. We have then exemplified, by
using the case of "Dana" from our previous publications, how it can be
employed in clinical practice. We hope that the message to take home after
reading this article is clear. Case study methodology is not rigorous or less
rigorous per se. It becomes rigorous or less rigorous depending on the type of
knowledge we want to generate in order to solve specific problems. This is
true for all the research methods. The problems which case study is best fit to
solve are those related to exploratory studies (i.e., generating new theories),
to critical, and unusual cases. It is less fit to test a theory although, if
conditions for falsifiability are met, it can be implemented with this purpose
as well. When used appropriately, case study methodology is very rigorous,
comparable with any other research method. By appropriate we mean two
things: (1) adequate to the problem it is intended to solve; and (2)
implemented at high standards in terms of internal constraints and steps that
need to be followed.

[Reference]

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[Author Affiliation]

Daniel DAVID*

Department of Psychology, Babes-Bolyai University, Cluj-Napoca, Romania

* Corresponding author:

Email: danieldavid@psychology.ro

Copyright A.S.C.R. Press Jun 2007. Provided by ProQuest LLC. For permission to reuse this article, contact
Copyright Clearance Center.
RATIONAL-EMOTIVE BEHAVIORAL
INTERVENTIONS FOR CHILDREN WITH ANXIETY
PROBLEMS
From:
Journal of Cognitive and Behavioral Psychotherapies
Date:
March 1, 2008
Author:
Wilde, Jerry
More results for:
APPLICATION OF REBT AND SELF ESTEEM publication:["Cognitie Creier
Comportament"]

http://www.highbeam.com/doc/1P3-
1454505541.html
Abstract

The purpose of this article is to provide detailed descriptions of specific

clinical interventions that can be used by REBT therapists working with
children and adolescents who are experiencing difficulties with anxiety. It is
worth noting that anxiety disorders are among the most commonly occurring
mental and emotional problems in childhood and adolescence. While a
majority of publications focus on empirical research, there is still a need for
articles that address clinical practices. REBT is, first and foremost, a system
devoted to the practice of psychotherapy. Whether it is through articles
focused on empirical research or clinical applications, the advancement of
REBT is the ultimate goal.

One of the most efficient anxiety management techniques involves the use
of distraction in which clients are encouraged to substitute a calming mental
image to interrupt the anxiety producing thoughts. This article also provides a
detailed explanation of rational-emotive imagery (REI), which is a technique
that employs relaxation prior to clients generating their own rational coping
statements. Finally, a progressive thought-stopping technique is examined. In
this intervention, the therapist provides successively less direction and
guidance in the hopes that clients will be able to master this technique for
use independently.

Keywords: anxiety, children, REBT

RATIONAL-EMOTIVE BEHAVIORAL INTERVENTIONS FOR CHILDREN WITH

ANXIETY PROBLEMS

Anxiety disorders are among the most common mental and emotional
problems to occur during childhood and adolescence. According to the U.S.
Department of Health and Human Services (1999), 13% of children and
adolescents ages 9 to 17 experience some type of anxiety disorder. In
community samples of adult populations, the range of anxiety disorders was
between 5 - 20% with a majority of the estimates lying above 10% (Costello
& Angold, 1995). Blanchard, et al., (2006) found that 36% of parents report
concerns about the possibility of their children struggling with anxiety.

If left untreated, anxiety disorders can persist into adulthood (Keller, et al.,
1992, Pfeffer et al., 1988; Spence, 1988) which may in part explain why the
lifetime prevalence rate for anxiety disorders is 28.8%, with a 12-month
prevalence of 18.8% (Kessler, R. & Merikangas, K., 2004). The same study
reported the most common subtypes of anxiety disorders to be specific
phobia (12.5%), social anxiety disorder (12.1%), and post-traumatic stress
disorder (6.8%).

REBT and cognitive behavior therapy (CBT) have an extensive history of

being successfully applied to anxiety problems in children (Brody, 1974;
Cangelosi, Gressard, & Mines, 1980; Cristea, Benga, & Opre,2006; DiGiuseppe
& Kassinove, 1976; Knaus & Bokor, 1975; Knaus & McKeever, 1977; Meyer,
1981; Micco, et al, 2007; Miller & Kassinove, 1978; Omizo, Lo, & Williams,
1986; Von Pohl, 1982; Warren, Deffenbacher & Brading, 1976; Wilde, 1994,
1995, 1996a). The utility of CBT with anxiety disorders has led mental health
officials in the United Kingdom to identify CBT as the first-line approach to
treating anxiety disorders (National Institute for Clinical Excellence, 2004).

Rational-emotive and cognitive-behavior interventions have also been found

to be beneficial in a host of other commonly occurring childhood problems
such as low frustration tolerance (Brody, 1974); impulsivity (Meichenbaum &
Goodman, 1971); poor academic performance (Block, 1978; Cangelosi,
Gressard, & Mines, 1980), and depression (Wilde, 1994). Research also
suggests that CBT is effective in the prevention of depression (Clarke, et al.,
2001, Gilliam, et al., 1995) and in the improvement of self-concept and
coping capabilities (DeVoge, 1974; DiGiuseppe, 1975; DiGiuseppe &
Kassinove, 1976; Katz, 1974; Maultsby, Knipping & Carpenter, 1974; Omizo,
Lo & Williams, 1986; Wasserman & Vogrin, 1979). Finally, several studies
have established cognitive-behavioral interventions to be effective in
increasing rational thinking in children and adolescents (DiGiuseppe &
Kassinove, 1976; Harris, 1976; Knaus & Bokor, 1975; Miller & Kassinove,
1978; Ritchie, 1978; Voelm, 1983; Wasserman & Vogrin, 1979; Wilde, 1997a).

What follows is a description of several rational-emotive and

cognitivebehavioral techniques that have been used in the treatment of
childhood anxiety disorders. It should be noted that this is just a sampling of
some of the more commonly used techniques and is not intended to be an
exhaustive list. A commonly asked question is, "Which is the best one?" It is
difficult, if not impossible, to answer because the answer ultimately depends
on the client and the situation. Therapists are encouraged to use their clinical
expertise to make those judgments.

THE USE OF DISTRACTION

The cardinal tenet of REBT is that emotions are not caused directly by
events but are primarily the result of the thoughts and beliefs an individual
has about the event. Therefore, if children are able to modify their thoughts
about an event, they will change their feelings as well. One of the simplest
and most effective techniques designed to bring about a change in thinking
involves the use of a distraction technique (Wilde, 1997b; Wilde 1996b; Wilde
1995).

Distraction is not an "elegant solution" as Ellis would say. It does not involve a
change in assessment of the event and, therefore, it would not be considered
to be bringing about cognitive restructuring. Distraction, as the name implies,
merely attempts to help children think of something other than their current
situation. This is more difficult than it sounds because when children are
getting anxious, the only thing they seem to be able to think about is the
situation at hand. That is why clients need to decide what to think about
before they start becoming anxious.

Encourage clients to pick "a scene" to use before they encounter the event
they become anxious about. This memory should be either the happiest,
funniest, or most relaxing scene they can remember. For example:

- A memorable day at the beach or on vacation

- The time they won a game

- A hysterically funny event from their past

- A memorable birthday party

Have clients take a few minutes and think about the distraction scene. You
may need to help clients select the scene that fits their individual needs. Now
they need to practice imagining this scene several times daily for the next
few days or weeks. When clients have some free time have them close their
eyes and picture their distraction scene. Clients should be advised to bring in
all the details that they can possibly remember to make the scene vivid.

What were the people wearing?

What were the sounds they can remember?

Were there any smells in the air?

Encourage clients to create scenes in their minds just like watching a

videotape of the event. It can also be helpful to have them draw their
distraction scene and then explain it to the therapist.

The idea is to switch to this distraction scene when the clients find
themselves getting anxious. Instead of focusing on the situation they are
getting anxious about, they are to concentrate on their distraction scene.
Instead of getting anxious before an important examination in school, they
are to concentrate on the distraction scene until the feelings start to subside.
Whenever they feel themselves getting anxious, they are to switch to their
scene.
It is impossible for clients to think of a distraction scene and still become
anxious. Since anxiety is produced by beliefs, thinking about a funny or
happy memory will keep them from getting upset or minimize the intensity of
the emotions.

RATIONAL EMOTIVE IMAGERY (A.K.A. THE IMAGINATION GAME)

What follows is an example of how the imagination game or rational-emotive

imagery (REI) can be used with children and adolescents who have anxiety
problems. Ellis (1994; 1979) and Wilde (1995; 1996a; 1997b) have used REI
extensively in the treatment of anxiety and anger problems. This technique is
most effective if there is a particular situation (i.e., certain social situations,
public speaking, separation from parents) in which anxiety is likely to occur.

Start by having the child vividly describe the troublesome scenario. Get as
many details as possible about the sights, sounds, and events in this
situation. Then have the child get as relaxed as possible in his or her chair
with both feet on the floor. Spend several minutes describing relaxing images
until you can see the behavioral manifestations of relaxations starting to
appear. The use progressive relaxation techniques with the successive
contracting and relaxing of various muscle groups can be very helpful. After
the client appears to be sufficiently relaxed, start with the following dialogue.

Therapist: Anna, I want you to listen very closely to what I'm going to tell you.
I want you to be aware only of my voice and focus on what I say. Try to block
everything else out of your mind for the time being.

Imagine you are back in your classroom and students are taking turns
reading aloud. Picture the room in your mind. See all the posters on the walls
and everything else that is in your class. Now go ahead and let yourself feel
like you do when it's reading time. Feel all the anxiety you felt back then.
Stay with that scene and try to feel just like you felt in the class. When you
feel that way, wiggle your finger and let me know you're there.

(Author's note - It's a good idea to look for behavioral signs confirming that
the child is actually feeling anxious. The jaw may tighten, eyebrows furrow
and many children will shift or squirm in their seats.)

Stay with that feeling. Keep imagining that you are in your classroom.

(Author's note - Allow the child to stay in this state for approximately 20 to 40
seconds. Remind him or her to mentally stay in the situation.)

Now I want you to keep thinking you are in the class but I want you to calm
yourself down. Stay in the classroom in your mind but try to calm down.
Instead of being very upset, try to get calmer. Instead of being really
anxious, try to work toward feeling calmer. Keep working at it until you can
calm yourself down. When you can make yourself calm, wiggle your finger
again.
Usually students can reach a state of relative calm within a fairly short period
of time. Once a child has wiggled his or her finger, it is time to bring him or
her back to the here and now. Simply say something like, "Okay, now open
your eyes." Next ask, "What did you say to yourself to calm yourself down?" If
the child was able to calm down, he or she had to be thinking some type of
rational coping statement. The only other way to calm down would be to
mentally leave the situation (i.e., no longer visualize the classroom). This
usually doesn't happen but if it does, try the exercise over encouraging the
child to keep imagining the scene but working to calm down.

After completing the imagination game students should then be able to state
the thought that allowed them to calm down. A typical calming thought that
might have been produced from the above scenario would be, "Even though I
don't read well, it's not that big of a deal. It doesn't mean I'm a bad person.
Other students have problems reading aloud."

Once the child has produced a rational coping statement, write it down. Now
he or she can practice this mental imagery several times a day and use this
same calming thought each time. In effect, this technique allows kids to
mentally practice dealing with a difficult situation in a new, more productive
way. It's very important that they practice REI on a regular basis if they are
going to learn to handle their anxiety in a more productive fashion.

Usually children can learn to do the Imagination Game by themselves after

having been led through the technique a few times by the therapist. It is also
possible to make a tape recording of this intervention for the child to use at
home as some students like using the tape rather than leading themselves
through this technique. Both can be effective if used regularly.

THOUGHT STOPPING

Ever since Joseph Wolpe (1958) first published descriptions of

thoughtstopping techniques, clinicians have been applying these types of
interventions. There has been a plethora of case studies published over the
years claiming reductions in anxiety symptoms with both adults and children.
However, the results of experimental investigations have been inconsistent.
Several of these studies have suffered from methodological shortcomings
such as the lack of a control group or no follow-up analysis to determine if
results have been maintained.

The general framework for teaching clients to use thought-stopping

techniques follows a progression that begins with the therapist being more
overtly involved and gradually diminishing involvement until the client is able
to use the intervention independently. This interventions starts by having
clients imagine the anxiety-provoking situation and vocalizing their thoughts.
When clients first utter an irrational anxiety-producing thought such as, "If I
did a bad job of reading in front of the class, I'd die," the therapist shouts,
"Stop." Practice this first step until clients report that the therapist shouting,
"Stop" interrupted their irrational thinking. The second step involves having
clients merely think of the anxietyprovoking situation and signal the therapist
whenever they were thinking an irrational thought. Upon observing the
signal, the therapist again shouts, "Stop."

It essential that the therapist spend time helping clients learn to distinguish
between rational and irrational thoughts. It is beyond the scope of this article
to delve too deeply into that issue. Interested readers can refer to Wilde
(1997a) for detailed information on teaching rational thinking skills to
elementary students.

The problem with most thought stopping interventions is that they stop at
this point. Clients can learn how to stop a disturbing thought but unless they
can replace the anxiety-producing thought with a rational cognition, the
original thought will quickly return. The next important step involves having
clients think about positive, rational and/or calming thoughts that could
substitute for the anxiety producing thought. Clients are taught to imagine
the anxiety-provoking situation and when they began to think irrational
thought they are to say their rational coping statement aloud. Once again,
practice this until clients report that they are able to consistently reduce their
anxiety to a manageable level. The use of a self-report scale (such as the
subjective units of discomfort scale) with a range from 1-10 can be helpful to
quantify the intensity of their emotions. The final step involves having clients
practice transferring the rational coping statement from an overt statement
to internal dialogue. Now they are to merely think their rational coping
statement whenever they notice they are beginning to feel anxious.

SUMMARY

Anxiety problems are among the most commonly diagnosed mental and
emotional problems to occur during childhood and adolescence. Research
suggests that if left untreated, many children will struggle with anxiety later
in life. The interventions discussed in this article are brief and not difficult for
children to learn. To maximize the potential for success, children need to be
closely monitored and given encouragement. Be prepared for both success
and setbacks during the course of treatment. Learning anxiety management
skills will take time and effort but the benefits are well worth the effort.

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[Author Affiliation]

Jerry WILDE *

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* Correspondence concerning this article should be addressed to: Email:

jwilde@indiana.edu

Copyright A.S.C.R. PRESS Mar 2008. Provided by ProQuest LLC. For permission to reuse this article, contact
Copyright Clearance Center.
CASE STUDY METHODOLOGY: FUNDAMENTALS
AND CRITICAL ANALYSIS
From:
Cognitie, Creier, Comportament
Date:
June 1, 2007
Author:
David, Daniel
More results for:
APPLICATION OF REBT AND SELF ESTEEM publication:["Cognitie Creier
Comportament"]

http://www.highbeam.com/doc/1P3-
1336338121.html
ABSTRACT

This article presents the fundamentals of case study methodology. After a

brief history, the presentation is based on a critical analysis to understand
the role and the place of case study methodology in scientific research. Thus,
both the advantages and the limits of this research method are discussed
and the step-by- step procedure is presented and then exemplified in a
clinical context.

KEYWORDS: case study research.

I. INTRODUCTION

1. A Brief History

The history of case study methodology as a scientific research procedure is

marked by periods of ups and downs. The earliest use of this form of
research can be related to psychophysics and medicine. In the United States,
this methodology was most closely associated with the University of Chicago.
In 1935, there was a public dispute between Columbia University
professionals, who were championing the "scientific methods" (i.e.,
experiment), and the "Chicago School" (Tellis, 1997). The outcome seemed to
be in favor of Columbia University and consequently the use of case study
methodology as a scientific research method declined (Tellis, 1997).

However, in the 1960s, researchers were becoming concerned with the

limitations of quantitative methods. Hence there was a renewed interest in
case study, although the case study methodology is not a pure qualitative or
quantitative method (Tellis, 1997).

Indeed, a quick PsycInfo based scientometric analysis confirms this history.

From 1806 to 1969 about 1319 articles dealing with "case study" and about
11171 articles dealing with "experiment" were published; the ratio is about 1
to 9. From 1960 to present, about 23151 articles dealing with "case study"
and about 46069 articles dealing with "experiment" have been published; the
ratio is about 1 to 2, which proves an increased interest in this methodology
in the psychological field.

The case study research method is defined as "an empirical inquiry that
investigates a contemporary phenomenon within its real-life context, when
the boundaries between phenomenon and context are not clearly evident,
and in which multiple sources of evidence are used" (Yin, 1984, p. 23). Thus,
case study methodology uses in-depth examination of single and/or multiple
case studies, which provides a systematic way of approaching the problem,
collecting and analyzing the data, and reporting the results.

Many proponents of case study methodology argue that it is a

comprehensive method usable for a large spectrum of problems (Yin, 1994).
On the other side, its critics argue that the study of a small number of cases
can offer no support for establishing reliability or generality of findings. Other
critics believe that the intense exposure to study of the case biases the
findings and that case study research can be use only as an exploratory tool
(see Susan, 1997).

The present article discusses the fundamentals of case study methodology.

We will not go into details, which can be found in many handbooks on this
topic. Rather, we will present the fundamentals in a critical manner so that
we can understand the condition of validity of the case study methodology in
scientific research, beyond the positions of its fervent supporters and critics.

2. When to use case study?

The aim of scientific research is to produce knowledge that can be used to

solve various problems, either theoretical or practical. Therefore, the use of
case study methodology as a scientific research tool will be determined by
the type of knowledge needed to solve a target problem. More precisely, a
case analysis methodology is rigorous and acceptable in scientific research
provided it meets the aims of the research. A review of the literature
suggests the following conditions in which case study methodology is
indicated in research.

(1) Case study methodology can be used as an exploratory methodology

helping to generate scientific theories. A scientific theory is an organized
system of propositions embedding knowledge. Some of these theories have
a descriptive role, while others have an explanatory and predictive role. As an
organized system of propositions, a theory also has a role in organizing our
knowledge about various phenomena.

(2) Case study methodology can be used to test a scientific theory. This is a
heated discussion in epistemology. As we have shown above, many critics of
the case study methodology think that the study of a small number of cases
cannot offer a basis for the reliability and generality of findings and thus, in
testing a theory.

The proponents of case study methodology (e.g., Yin, 1994) defend it by

arguing that (1) the generalization of results is made to the theory not to
populations; and (2) case study methodology provides generality by
replication rather than sampling logic. Typically, a theory is tested based on
two procedures: verification (i.e., trying to find examples congruent with its
predictions) and falsification (i.e., trying to find counter-examples to its
predictions). In our opinion, case study methodology can be used to test a
theory in the second case only. According to Karl Popper,
falsification/falsifiability is the most rigorous method to test a scientific
theory. Falsifiability implies that for an assertion to be falsifiable it must be
logically possible to make an observation that would show the assertion to be
false. Thus, if only one observation does not fit with the assertion, it will
invalidate the theory, which should be either dismissed or revised. Case study
methodology is very much appropriate to rigorously identifying and analyzing
such crucial observations. Having said that, we remind our readers the Quine-
Duhem thesis, which argues that each theory is tested in conjunction with a
number of auxiliary hypotheses. If a prediction is falsified, this could mean
that there is something wrong with the conjunction between the theory and
the auxiliary hypotheses rather than the theory is false (Greenwood, 1989).
Thus, Quine argues that a scientist is never forced to reject a theory in the
face of recalcitrant data; the theory can be preserved by the modification of
the auxiliary hypotheses (Greenwood, 1989). In the case of verification,
replication (e.g., by including multiple case studies) provides indeed support
for generality but because the cases are not in the same framework (i.e., the
same context and time) as in sampling logics, the probability of error is
increased. To make a long story short, in theory, case study methodology can
be used to test a theory by following a falsification rather than a verification
logic; however, in practice it is hard to meet this condition for the reason
briefly discussed above.

(1) Case study methodology can be used to exemplify an already validated

theory. This is very important for didactical reasons and for reinforcing an
already validated theory because this condition can also be conceptualized as
an effort to further test the theory following the falsification logic described
above.

(2) Case study methodology should be involved in research when knowledge

is intended to be used and refers to the investigated case studies only.
Indeed, case study methodology uses in-depth examination of single and/or
multiple case studies, and thus, it provides a systematic way of rigorously
understanding these cases.

(3) When no other cases are available (i.e., critical and/or unusual cases), the
researcher is limited to case study methodology (i.e., single-case design). If
the objective is similar to that described at point 4, case study should be the
choice research methodology.

3. When to avoid using case study?

Case study is not useful in testing a theory based on verification, and then
arguing that the theory is validated. Generally, the choice for or against case
study methodology depends on the problem we have to solve. If the problem
implies knowledge based on sampling logics, case study methodology should
be avoided.

4. Case Study Step-by-Step

There are several components of a good case analysis methodology:

a. The research should start with the problem - the study question. The
problem can be defined as a discrepancy between an initial state (what he
have) and a final state (what we want to have). A rigorous problem will define
precisely the initial state and will specify clearly the objectives. A serious
problem is one in which the discrepancy between the initial and final states is
approachable by current methodology. For example, if my proposed final
state is to eliminate all mental disorders in the next two years, this will not be
considered a serious problem considering current knowledge in clinical
psychology and medicine.

b. The objectives and/or the hypotheses should be made clear (if they exist).

c. The next step involves defining the unit of analysis and than data
collection. It must be made clear that data collection can be guided by either
quantitative and/or qualitative methods. Data can come for various sources
and depending on the problem and objectives, it can be collected
qualitatively (e.g., by interview) and/or quantitatively (e.g., numerically).

d. Once collected, the data is analyzed quantitatively and/or qualitatively. If it

was collected qualitatively (e.g., by interview) it can be analyzed either
qualitatively (e.g., thematic analysis) or quantitatively (e.g., frequency). If
data was collected quantitatively (numerical) it can be analyzed
quantitatively, either inferentially or descriptively.

e. In the next step, logic is used to link our results to our objectives and/or
hypotheses. This is where people who use case study methodology make
most mistakes (e.g., generalize when it is not the case). Therefore, it is
fundamental to binocularly integrate the logics and the design of the study to
avoid such errors.

f. Finally, based on the aspects discussed at point "e", conclusions and

discussions should interpret the findings in the particular context and in the
larger context of the scientific literature on the topic.

Having presented the fundamentals of case study methodology let us now

try to exemplify its use in clinical practice. Based on the above presentation,
we use case study methodology to: (1) exemplify an already validated theory
(with didactical purposes) and (2) to further test this theory based on the
falsification principle; more precisely, if the theory is to be invalidated we
expect no success in the treatment of this clinical case.

II. APPLICATIONS
Case Study in Research (adapted after David & McMahon: "Clinical strategies
in cognitive behavioral therapy; a case analysis" published in the Romanian
Journal of Cognitive and Behavioral Psychotherapies, vol. 1, no. 1, September
2001, pp. 71-86; see also David, 2003; David et al., 2004; David, 2006a;
2006b). The case of "Dana" is a classic one in the Romanian clinical
literature; this is why it is presented based on its previous publications,
although the context is new (i.e., case study methodology).

1. The Problem

1.1. Introduction

Many people find the distinction among "Behavior Therapy (BT)", "Cognitive
Therapy (CT)", "Cognitive Behavior Modification (CBM)", and "Rational
Emotive Behavior Therapy (REBT)" confused and confusing (Dobson, 2001;
Lazarus, personal communication). We believe that the time has come to stop
elaborating on details regarding the various schools and systems of cognitive
behavior therapy/therapies (CBT), and (1) to focus on the science and theory
of cognitive behavior therapy; (2) to discuss treatments of choice for specific
conditions; (3) to focus on what is and what is not empirically supported; and
(4) to develop really good manuals so that experimentally oriented clinicians
can endeavor to test, repudiate or replicate particular claims and findings. We
think that all these goals can be accomplished under the umbrella of
cognitive science. Cognitive science attempts to understand the basic
mechanisms governing human mind, basic mechanisms that are important in
understanding behavior studies by other clinical and social sciences.
Cognitive science studies the foundation on which many other social and
clinical/psychological sciences stand (Anderson, 1990).

We believe that cognitive science could be a setting for theoretical

integration within CBT (see also, Ingram & Siegel, 2001). A well-integrated
CBT should easily support different therapeutic strategies in a coherent
theoretical framework. In my opinion, even if there is a strong premise for a
coherent theoretical framework in CBT, an artificial division is maintained
because of the confusion among assumptions/paradigms, theories/models,
and clinical practice debates in CBT. A paradigm is a general pool of
constructs and assumptions for understanding a domain, but it is not tightly
enough organized to represent a predictive theory (Anderson, 1983).
Although at this level we could find incompatible differences among different
schools of CBT, we do not have the tools that would allow us decide which
one is right and which one is wrong. The paradigm is not a level of
conceptualization for disputation or integration. A theory provides a
predictive deductive system, while a model is the application of the theory
to a specific phenomenon. It is at this level of theories and models that we
argue for a coherent science of CBT, based on empirical evidence. Practice
refers to the application of therapeutic strategies and techniques.
Strategies and techniques should be numerous, different and theory driven
so we can check for their efficacy under different conditions.
Our basic argument is that CBT should be driven by cognitive science theory
in clinical research and theory, case conceptualization, and empirically
validated treatments of choice for specific conditions. In the next section of
this article, we discuss (1) some brief considerations on cognitive science and
the theory of emotions, with implications for theoretical integration within
CBT; (2) a case conceptualization based on the theoretical considerations;
and (3) a CT strategy and an elegant REBT strategy to change the target
cognitions in order to change the emotional difficulties. The inelegant REBT
(see Ellis, 1994 for details about the distinction between elegant and
inelegant REBT) seems to be similar with CT so that such a comparison
becomes redundant. Pros and Cons for each strategy are briefly mentioned.

1.2. Cognitive science and emotional problems; A brief presentation (see also
David, 2003; David et al., 2004)

Any analysis of cognitions should take into account a fundamental distinction

between "knowing" and "appraising" (Wessler, 1982). Abelson and Rosenberg
(1958) use the term "hot" and "cold" cognitions to make the distinction
between appraisal (hot) and knowing (cold). According to Lazarus and Smith
(1988) cold cognitions refer to how people develop representations of the
relevant circumstances (i.e., about activating events). Such circumstances
are often analyzed in terms of surface cognitions (easy to access consciously)
and deep cognitions (more difficult to access consciously). Surface cognitions
refer for example to inferences and attributions, while deep cognitions refer
to schemas and other meaning-based representations (for details see
Anderson, 1990; Lazarus, 1991). Hot cognitions refer to how people further
process cold cognitions. They can be more or less abstract (e.g., "It is awful
when my wife does not listen to me" versus "It is awful when people do not
listen to me"). The terms appraisal or evaluative (hot) cognitions are used to
define the processing of cold cognitions and their relevance for personal well-
being (for details see Ellis, 1994; Lazarus, 1991). Consequently, during a
specific activating event, there are different possibilities regarding the
relationship between cold and hot cognitions related to the activating event:

(1) distorted representations of the activating event/negatively appraised;

(2) non-distorted representation/negatively appraised;

(3) distorted representations/non-negatively appraised;

(4) non-distorted representations/non-negatively appraised.

According to Lazarus (1991) and the appraisal theory of emotions, although

cold cognitions contribute to appraisal, only appraisal results in emotions.
Some previous influential research programs showed that cold cognitions
(i.e., attributions, inferences) were strongly related to emotions (e.g.,
Schachter & Singer, 1962; Weiner, 1985). However, according to more recent
developments in cognitive psychology, cold cognitions are relevant to
emotions because they contribute to the data we evaluate with respect to
adaptive significance. Now it is generally accepted that as long as the cold
cognitions remain unevaluated, they are not sufficient to produce emotions
(Lazarus & Smith, 1988; Lazarus, 1991; Smith, Haynes, Lazarus, & Pope,
1993).

Following the previous distinction between hot and cold cognitions, according
to the appraisal theory of emotions, emotional problems will only appear in
cases 1 (distorted representation/negatively appraised) and 2 (non-distorted
representation / negatively appraised). In case 1 (distorted representation /
negatively appraised), if one changes the distorted representations (e.g., "He
hates me") into an accurate one (e.g., "He does not hate me"), one may end
up changing the negative emotion (anxiety) into a positive one (happiness).
However, the individual may still be prone to emotional problems because
the tendency to make negative appraisals (e.g., "It is awful that he hates
me") is still present. If one changes the negative appraisal (e.g., "It is awful
that he hates me") into a less personally relevant one (e.g., "It is bad that he
hates me but I can stand it"), it is probable to change the dysfunctional
emotion (anxiety) into a functional but still negative one (concern; for the
distinction between functional and dysfunctional emotions see Ellis, 1994). A
strategy that will change both distorted representation and negative
appraisal seems to be a better choice. In case 2 (non-distorted
representation/negatively appraised), the choice seems to be the change of
negative appraisal that would generate a positive (happiness) or negative
(concern) functional emotion. Another possibility is to change a non-distorted
representation (e.g., "He really hates me") into a positively distorted one (i.e.,
positive illusion: "His negative comments are a way of communicating that
he considers me a strong and reasonable person"). However, as in the first
case, in the second situation we may change both representation and
negative appraisal.

We believe that a clinical case conceptualization based on cognitive science

should take into account both processes: cold cognitions and hot cognitions.
Although this idea is generally accepted in the clinical literature, Wessler and
Wessler (1980) note that in CBT we do not always clearly differentiate cold
from hot cognitions. Moreover, this distinction is opaque in practice (Wessler,
1982). For example, in REBT both cold cognitions and hot cognitions are
mentioned, but the clinical conceptualization is focused on evaluative/hot
cognitions (irrational beliefs). Cognitive therapy focuses mainly on cold
cognitions, both of surface and deeper level. Even if Beck (1976) argues the
certain schemata involve evaluations and that schemata are similar in
breadth to Ellis's irrational beliefs (DeRubeis, Tang, & Beck, 2001), CT case
conceptualization and interventions are more focused on cold cognitions
(e.g., inferences, attributions, automatic thoughts) rather than on evaluative
beliefs. Generally, CT focuses more on cold cognitions, that is, facts that can
be empirically validated, while REBT focuses more on the hot cognitions, that
is, evaluative cognitions (Dobson, 2001). Because clinical intervention is
driven by case conceptualization often not involving a clear distinction
between hot and cold cognitions, many artificial misunderstandings appear.
We believe that case conceptualization should be theory driven, and that it
should take into account both cold and hot cognitions. This way, CT and
REBT techniques could be seen as different therapeutic strategies in a
coherent theoretical and clinical framework. Within this framework, the
pseudo-problem of CT versus REBT can be replaced by a discussion on
strategies of choice to change different types of cognitions.

2. Clinical case; History, clinical conceptualizations and treatment

2.1. Case History

Dana is a 28 years-old physician, mother of one, who lives with her husband,
and who has been working full-time as a fellow in gastro-enterology for the
past 3 years.

Chief Complaint. Dana sought psychological treatment for panic attacks and
generalized anxiety at the end of and the beginning of 2000 (18 sessions).
Two months before treatment she had had three panic attacks and feared
having another one. She also reported: "Since about 1991, I have been
feeling nervous and excessively anxious about my life (e.g., "my future job as
a physician"), my relationships (e.g., "with colleagues and my husband") and
my significant activities (e.g., "my school performance, my doctorate"), but
right now I am much more concerned about the recent panic attacks".

History of Present Illness. In 1991, Dana moved away from home, far from
her overprotective parents, to study medicine at a prestigious university.
Starting then she began feeling helpless and she reported attacks of
excessive anxiety and "worry about everything" (emotional symptoms).
These emotional states were often associated with muscular tension, feelings
of weakness, fatigue, and sleep disturbance (physiological symptoms). She
always found it difficult to control these physical symptoms and,
consequently, she started avoiding activities that required physical effort
(behavior symptoms). She thought that her symptoms would affect her
performance at work and her value as a competent human being (cognitive
symptoms); consequently, she often felt helpless, with low self-esteem. Her
GP and then a psychiatrist prescribed her Buspar (Buspirona) (in 1993). After
several months of medical treatment, she gave it up, as it had reduced
symptoms less than she expected. The first panic attack occurred while she
was preparing for her doctoral exam about two months before our first
meeting (1999). About one month later she had another attack. At the time
of the second attack she was at home cleaning her apartment. The third
panic attack occurred just one week before our first meeting, while she was
home alone, preparing a paper for a scientific congress. Her panic symptoms
included the following: Emotional symptoms: intense fear of loosing control,
helplessness and discomfort; Cognitive symptoms: believing that she was
going to die, had heart problems, and that she was going to faint and
collapse; Behavioral symptoms: avoiding physical effort and looking for safe
places in case she fainted; Physiological symptoms: palpitations, trembling,
and chest pains. She consulted a psychiatrist regarding these symptoms, and
was prescribed XANAX just two months before our first meeting.

The major stressors in Dana's life were mainly social. She was an
overprotected child, and being far from home and from the protection of her
parents during training in medical school was the first major stressor that
might have precipitated her generalized anxiety (1991). Moreover, before
getting married (she got married in1998), Dana had hoped that her husband
would be a real support for her. She believed that he could help her to
overcome her anxiety and her "worries about everything". Unfortunately, her
husband's job was highly demanding. He was an assistant professor and a
researcher often working hard late at nights and on weekends. He was not
very involved in the household and in their child's education (the birth of
Dana's son was another stressor and opportunity for her to worry about:
"Considering that I am so busy, how will I have enough time for my son?").
Consequently, she felt overwhelmed by her life as wife, mother, physician,
and student, doing her full-time job as physician, cleaning the apartment,
cooking, taking care of her son, and preparing for her exams doctoral exams.
These were the conditions in which her first panic attacks developed (1999).

Personal and Social History. Dana was an only child. She described her father
as very rigid, controlling and concerned with the future of his daughter.
Because of his authoritative attitude she had been afraid to argue with him
or ask something from him (the same thing is true even now as an adult). She
described her mother as a warm person, highly concerned with the education
and the future of her daughter. Dana remembered that during kindergarten,
primary and secondary school she had been overprotected by her parents but
that she had not liked that attitude at all. For example, every morning they
left her at school and in the afternoon they picked her up. Because of this,
she had no opportunity to have friends and/or be with her colleagues. She
described herself as a girl (and now a woman) with very poor social and
assertiveness skills both at home and in other social situations. During high
school she started preparation for medical school. Both parents wanted her to
attend medical school. They allowed her to have a boyfriend (the relationship
was not very intense); however, they were only allowed to meet at her home
or go out for several hours in the afternoon. After starting medical school
(1991), Dana had to move to another town. During the first year (she was 18)
her parents visited regularly. They did not want her to live in a dorm with her
colleagues, so they rented an apartment where she could learn without being
disturbed by others. During her first year in medical school she started
experiencing intense signs of generalized anxiety and some symptoms of
subclinical depression. She felt alone, helpless, and started to worry about
everything (but not about the separation from her parents - this was one of
the reasons why we did not consider a diagnosis of separation anxiety!).
During her second year of study (1993) she decided to see a general
practitioner and a psychiatrist who prescribed her Buspar (Buspirona). After
several months she gave up treatment because the symptoms of generalized
anxiety persisted. Despite these symptoms she graduated medical school
successfully in 1997 and started working as a fellow in gastro-enterology. She
met her husband around the same. She described him as very bright, strong
and mature man, 15 years older than she was. They fell in love and got
married in 1998. They live in the same town where she graduated medical
school. After one year of marriage their son was born. In 1998 she started a
doctoral program in medicine. During their second year of marriage (1999)
she experienced her first panic attack. I (DD) met her in 1999 after she had
experienced three panic attacks. Beside psychotherapy, Dana took
medication (XANAX) prescribed by her psychiatrist.
Medical history. Dana had no medical problems which could influenced her
psychological functioning or the treatment process.

Mental Status Check. The patient was fully oriented with an anxious mood.

DSM IV Diagnoses. Axis I: Panic disorder without agoraphobia and generalized

anxiety disorder (subclinical depression - the patient has some symptoms of
depression but she does not meet the full criteria for any depressive
disorder); Axis II: None. The patient does have some dependent personality
traits. However, a careful analysis has revealed that dependent behaviors
seem to be related to the anxiety disorders and that an independent
diagnosis of dependent personality disorder is not justified; Axis III: None;
Axis IV: Inadequate social support, overwhelmed by life circumstances (e.g.,
housing problems, demanding work conditions, educational solicitations);
Axis V: GAF 60 (current -1999-). Best during the past year - 70.

2.2. Case formulation/conceptualization; A cognitive therapy perspective (by

Dr. Daniel David)

A. Precipitants. Dana's separation from her overprotective parents, her lack

of social and assertive skills, and her immersion in a completely new context
(e.g., new town, new colleagues, new requirements) probably precipitated
and then maintained the generalized anxiety and the subclinical depression.
The panic disorder may have been precipitated by lack of support from her
husband and because she felt overwhelmed by her duties. She expected her
husband to support her emotionally. In fact, after getting married, she felt
overwhelmed, and that she had more duties than before. This is when she
experienced her first panic attack.

B. Cross-Sectional of Current Cognitions and Behaviors. Typical of Dana's

current problematic situation was the one related to her first panic attack.
While preparing for her doctoral exam in her room, she had the following
automatic thought: "I will not be able to prepare properly over the next few
days because nobody helps me with my other duties and nobody can give me
more time to prepare for the exam" (surface cold cognition: automatic
thoughts). Emotionally she felt anxious, stopped reading, and jumped out of
her chair. Then she started to experience shortness of breath, chest pain,
palpitations and uncontrollable trembling. At that moment she had another
automatic thought/catastrophic interpretation: "I am sick and I am having a
heart attack" (surface cold cognition: automatic thoughts). Her symptoms
became more intense (panic about panic-secondary emotion) and the world
seemed strange and unreal. Emotionally she felt fear and intense discomfort.
She went out of the room and tried to reach the bathroom to wash her face
with cold water. A second typical situation is illustrated by the second panic
attack. While she was cleaning her apartment she started having palpitations.
Her automatic thought/catastrophic interpretation was: "Not again. I will die
and nobody will take care of my son" (surface cold cognition: automatic
thoughts). Over the next few minutes she developed another panic attack
with palpitations, chest pain and trembling. She tried to reach an armchair (in
case she fainted) and the phone in order to call her husband (she did not call
him). A third situation occurred when she was preparing a paper for a
scientific congress. She thought: "I don't have enough time to prepare a very
good paper. Nobody helps me have more time" (surface cold cognition:
automatic thought). She started having palpitations and almost immediately
thought/made a catastrophic interpretation: "Oh, my God, I am really sick. I
am going to faint and collapse" (surface cognition: automatic thought). Within
a few minutes, she experienced the third panic attack but this time the fear
of losing control or going crazy was stronger. She went into the living room to
be closer to the phone and she sat down in the armchair trying to relax.
Despite assurance by her GP that nothing was wrong with her physical
health, Dana still related her panic and anxiety attacks to an undiagnosed
physical illness. Even though she was open to referral for psychotherapy, she
was not very open to a psychological conceptualization of her problems.

C. Longitudinal View of Cognitions and Behaviors. Dana grew up with very

protective parents. He job was to learn well. Her parents took care of
everything for her. She had plenty of time to organize learning activities.
Consequently, she was a very good student. Three core beliefs (deep cold
cognitions) developed in connection with her past experiences. The first core
belief (schema) refers to competence: "doing everything at high standards".
This deep cold cognition is often appraised: "I have to do everything at high
standards otherwise I am inadequate, unlovable and weak" (hot cognition).
The second core belief refers to both responsibility and control: "If the others
do not support me, I am not able to focus on, to control and succeed in
important things in my life". This deep cold cognition is further appraised:
"Significant people in my life must help me control my environment in order
for me to focus on and to reach my important objectives. If they don't, it is
awful and I can not stand it" (hot cognition). The third core belief is related to
comfort and control and it seems to be linked to secondary emotions (i.e.,
panic about the panic): "If I am helpless and cannot control myself, I and the
others will suffer". It is negatively appraised: "I have to be in control
otherwise it is awful and I cannot stand it" (hot cognition).

D. Strengths and assets. Dana is a bright person with a good physical health.
She loves medicine and she is very disciplined. She wants the best for her
and her family and consequently, no effort is to high to attain these goals.
She has lived with generalized anxiety for almost 7 years. The coping
mechanisms she employed during these years were: avoiding problems,
avoiding physical exercise and studying hard.

E. Working hypothesis. Dana experienced generalized anxiety because her

core beliefs made her interpret a wide range of situations as threatening. Her
separation from her parents and her immersion in a completely new
environment (e.g., new town, new colleagues, higher requirements than in
high-school) probably precipitated the generalized anxiety and the subclinical
depression by activating these core beliefs. Moreover, her lack of
assertiveness and social skills (e.g., dependent personality characteristics)
could have amplified and contributed to anxious and depressive symptoms.
Later, by corroborating this background of generalized anxiety with (1) the
pressures in her life after marriage and (2) the frustrations concerning the
expected support from her husband, the panic attacks developed. Panic
attacks were stimulated by her catastrophic interpretations, which often
generated panic about the panic.

2.3. Treatment plan; A cognitive therapy perspective (by Dr. Daniel David)

A. Problems list: (1) Dana's panic attacks; (2) general feeling of worry about
everything (generalized anxiety and subclinical depression); (3) relationship
with her husband concerning the support he might offer to her (4) low
selfesteem and social and assertiveness skills.

B. Treatment goals: (1) to reduce panic attacks (including panic about panic);
(2) to reduce negative distorted thinking with impact on generalized anxiety
and subclinical depression; (3) to build assertiveness and problem solving
skills in order to improve the relationship with her husband and her ability of
solving practical problem; (4) increase social skills with impact on her
dependent personality traits.

C. Treatment plan. The treatment plan was to first reduce Dana's panic
attacks (including panic about panic) and then her generalized anxiety and
subclinical depression. We also planned to work on her assertiveness, self-
esteem, and social skills. Finally, some practical problems were approached
and a relapse prevention program was introduced.

For panic attacks we used a treatment package involving: (1) cognitive

restructuring techniques (Clark, 1995) to reduce catastrophic interpretations
(automatic thoughts) and (2) hyperventilation/controlled breathing
techniques (Ost, 1987) to explain (partially) and control panic symptoms. A
distraction technique was also used at the beginning of the intervention with
both didactical (cognition versus emotion) and therapeutic (quickly help
symptom management) role. The panic package was then adapted for
generalized anxiety and subclinical depression, and it consisted of: (1)
cognitive restructuring techniques (Beck, 1976; Clark, 1995) to change
automatic thoughts and core beliefs and (2) relaxation techniques (Ost, 1987)
to reduce the chronic arousal. We also focused on changing (at different
levels of abstractions) the evaluative cognitions associated with the core
beliefs. In order to enhance assertiveness and social skills we used
assertiveness training, social and problem solving skills training, to help her
become more self-confident and less dependent. The treatment package was
implemented as follows.

1. The patient was taught a distraction technique for panic attacks (e.g., to
describe in detail all the objects in the room). This technique: (a) would
counter Dana's belief that she had no control over her anxiety; (b) be a useful
symptom management technique when it was difficult to challenge automatic
thoughts; and (c) be a potent demonstration of the cognitive model of
anxiety to which Dana was initially quite reluctant. She was then introduced
to voluntary hyperventilation technique. This was useful in modifying her
catastrophic interpretations of the bodily sensations she experienced during
panic attack. Controlled breathing was also introduced with the purpose of
reducing hyperventilation.
2. The patient was taught standard cognitive restructuring and behavioral
techniques for her automatic thoughts, catastrophic interpretations, and later
for her core beliefs. We also focused on changing hot cognitions by working
at different levels of abstraction. These techniques allowed Dana to
understand maladaptive thoughts and assumptions and thus significantly
reduced anxious and panic symptoms, subclinical depression, and some of
the dependent traits.

3. Dana was taught a relaxation technique and a controlled breathing

technique. The relaxation technique was expected to mainly impact on
generalized anxiety, as it reduces chronic arousal.

4. Assertiveness training and social and problem-solving skills were

introduced in order to improve her interpersonal relationships (particularly
with her husband) and problem solving abilities. These interventions would
also help her be less dependent.

5. A relapse prevention program was introduced at the end of the treatment.

Obstacles. As she was trained as a physician in the bio-medical model, it was

hard to convince Dana about the relationship between cognition and emotion
using a conventional approach. Thus, the rationale of treatment (e.g.,
relationship between cognition and panic attacks) was not forced upon the
patient. Instead, more techniques were used than with other patients to
illustrate this relationship: (1) bibliotherapy - books on psychosomatic
medicine, cognition, and emotion; (2) more examples including literature on
the experiments (cognition-emotion relationship) of Schachter and Singer
(1962). At the end of this educational program the patient was very surprised
about the influence of cognition over emotion and was eager to introduce
these ideas not only in our work but also in her work as gastro-enterologist.

Outcome. Dana's therapy extended over 18 sessions. Six months after the
end of therapy, Dana had no recurrence of panic attacks or symptoms of
subclinical depression. However, some symptoms of generalized anxiety
persisted but they did not meet the DSM IV criteria for generalized anxiety
disorder. Dana's assertiveness and social skills improved significantly and had
a positive impact on her relationships (including with husband and parents)
and on the reduction of dependent personality characteristics. All these
results are operationalized in a single case experiment design: multiple
baselines across symptoms.

2.4. Case Formulation; An REBT perspective (by Dr. James McMahon)

This married medical student, 28, mother of a child, tried medical/psychiatric

interventions without success at first, and, with the realization that she would
become addicted to increased use of medication to ward off anxiety
symptoms, tried psychological intervention latter. When her thoughts turned
to feelings of worry and worthlessness, she panicked and was unable to
believe in herself and her ability to manage herself. These beliefs were put
into place later in life; while she was able to achieve academically through
her life, because she was overprotected, she had few skills that enabled her
to believe in her own general self management. Escaping from rigid
protection, she went on her own into an apartment and she eventually
married. She demanded (demandigness - DEM) that her husband take the
place of her parents to some extent by providing her with support and rules.
He did not. Instead, he cooperated with her in baby making, he went about
his career and he left Dana with her own career as well as with house and
childcare responsibilities. To deal with panic and anxiety, it was
conceptualized that Dana has superior intelligence, that she could make
logical, empirical and pragmatic distinctions/disputations, and that she would
work within rules to change her dependency. She was willing to read and
engage a given/take process of therapy, and she was willing to keep a log of
behavior. A careful analysis revealed many types of cognitive distortions,
both surface and deep (see Dr. David's analysis) and a group of irrational
beliefs (evaluative cognitions) like: (1) demandigness - DEM (e.g., "I have to
do everything at high standards; the others have to help me", etc.); (2)
awfulizing - AWF (e.g., "If I am not in control it is awful"); (3) low-frustration
tolerance -LFT (e.g., "I cannot stand it") and selfdowning - SD (e.g., "I am
weak and inadequate").

2.5. The treatment plan; An REBT strategy (by Dr. James McMahon).

Treatment was conceptually divided into four components: (1) immediate

management of panic through ego anxiety and discomfort anxiety theory
and practice; (2) unconditional self and other acceptance with impact on
generalized anxiety, sublinical depression and dependent characteristics; (3)
practice against regression through logical, empirical, and pragmatic
disputation as well as recognition of irrational beliefs; (4) solving some
practical problems. These four distinctions integrated, it was conceptualized
that Dana could (a) be happy as a person who liked herself, (b) become self-
managed rather than reach out to others to provide management for her, and
(c) that she could work against regression to irrational beliefs with simple
reading and practice. In addition to cognitive restructuring of irrational
beliefs, it was suggested that Dana engage philosophical change by
distinguishing who she was from what roles she played. A distinction between
practical and emotional problems was made and the patient realized the
usefulness of focusing first on the emotional problems and then on the
practical problem. The emotional problems were separated into primary
emotional problems (panic and generalized anxiety) and secondary emotional
problem (panic about panic).

An REBT treatment regimen was put into place, the process of intervention
was commented upon and acceptable to both patient and therapist. Several
issues were emphasized to her namely, that the idea was to be better not get
better, that two primary aspects on the neurotic continuum of thinking-
feeling were her tendency to exaggerate (awfulizing) and to avoid negative
emotions, thereby giving her temporary comfort but long-term misery (low
frustration tolerance). Also it was discussed with Dana how her problems
seemed to be related to demandigness oriented to her own person (e.g., "I
have to do everything at high standards") and others (e.g., "Others have to
help me"). If these demands are not attained, then she moves into self-
downing (e.g., I am weak), awfulizing (e.g., "It is awful") and low frustration
tolerance (e.g., "I cannot stand it"). Session 2-4 went to the heart of panic.
Checked was the secondary problem (panic about panic) and the irrational
beliefs involved (e.g., "I have to be in control otherwise it is awful and I
cannot stand it"; DEM, AWF and LFT). The primary emotional problem was
then focused upon (where we identified others DEM, AWF, LFT and SD).
Session 5-7 stressed self-worth issues related to generalized anxiety and
subclinical depression (e.g., stubborn refusal to judge herself, examining her
roles and how to judge them through the who/what process, rational-emotive
imagery in which she perceived herself to be in control of her own life and
that she was in charge, and disputation of other irrational beliefs). Sessions
8-12 involved further restructuring of IBs into adaptive alternatives (at
different levels of abstraction) and how to distinguish beliefs from feelings
about beliefs. She kept a log of the type of empirical, logical and pragmatic
disputations. Session 13-18 involved dealing with issues of dependency
throughout her life, looking for alternative conceptions. Some practical
problems were approached, and revisiting panic and anxiety situations was
undertaken to preclude regression.

Outcomes. Dana reported in the last session that she was free of panic
attacks, that she could distinguish rational from irrational beliefs, and that
she generally felt happy and liked herself. Regarding her own goals, she
indicated that she was generally happy but busy with her family and work,
that she judged that she could head off panic attacks in the future, and that
she was assertively negotiating home duties with her husband. The patient
and the therapist judged that she achieved good results therapeutically and
as a person.

2.6. Discussion

2.6.1. Comment upon the cognitive therapy strategy (by Dr. James
McMahon).

The work of Dr. Daniel David was generally masterful: good diagnosis, good
interventions, and the goals were attained. He used all available CBT
techniques that were appropriate by distinguishing automatic thoughts vs.
core beliefs vs. evaluative cognitions. However, I would mention that the
distinction between core beliefs (cold cognitions) and evaluative cognitions
(hot cognitions) is not always clear in cognitive therapy, although here, Dr.
David made it very clear. Also, many cognitive therapists prefer to work only
at the level of distorted cold cognitions, both surface and deep, rather than
at both cold cognitions and evaluative beliefs. In that case, the patients may
feel better but not get better. For example, they may feel better because the
activating events (e.g., "It is not true that she laughs at me") are not
dangerous, but the individual still may be prone to emotional problems
because the tendency to make negative appraisals (e.g., "It is awful when she
laughs at me") of activating events incongruent with their goals (e.g., "She
really laugh at me") is still present. However, here, Dr. David approached
correctly both types of cognitions. If there were one negative aspect, that
would be that therapy did not get to the person. Rather, therapy dealt with
symptoms, and then their causes and cure. While achieving personhood in CT
can be inferred, it can only be inferred as one of the several schemas since
the theory purports to be empirical and so deals with piece-by-piece
examples of pathology. Contradistinction, REBT theory clearly tries to
achieve fundamental philosophical change and so is person driven.

2.6.2. Comments upon REBT's strategy (by Dr. Daniel David).

I think that Dr. McMahon's elegant REBT is really elegant: great clinical
approach! Unlike me, Dr. McMahon attacked evaluative cognitions directly. I
myself would approach evaluative cognitions, but after a careful challenging
of automatic thoughts and core beliefs. My general criticism to Dr. McMahon's
approach would be that by directly changing evaluative cognitions and
assuming that distortions are real (e.g., "Let us suppose that you are indeed
not able to work at high standards; How does this make you weak and
inadequate as a person?" or "How is this awful?", etc.) one may change a
dysfunctional emotion (anxiety) into a negative functional emotion (concern)
because automatic thoughts (e.g., "I will not be able to prepare my
presentation") and deep cold cognitions are not directly disputed in the
elegant REBT. I know that Dr. McMahon might suggest that by changing
evaluations one indirectly changes distortions too, and indeed, one may
invoke some corpus of research which supports this hypothesis (Dryden,
Ferguson, & Clark, 1989 but see Bond & Dryden, 2001). However, sometimes
distortions may gain functional autonomy from the evaluative cognitions (see
Allport's concept of "functional autonomy"); in this case the change of
evaluative cognitions might not be accompanied by a change in the
distortions. Consequently, the client may feel better (e.g., "concern" rather
than "anxious") but not achieve the best results (e.g., "relaxed", "calm" or
even "happy"). On the other hand, as Ellis repeatedly mentions, (Ellis, 1994),
not all patients may benefit directly from elegant REBT. However, in our case
the patient seems to be in a positive emotional state and thus, Dr. McMahon's
direct disputation of IBs also seemed to change cognitive distortions (i.e.,
elegant REBT). If that had not happen, I suppose that Dr. McMahon would
have forcefully disputed the distortions too (i.e., inelegant REBT). The
difference between our approaches seems to be in terms of strategy. I
started with automatic thought, core beliefs and then evaluative cognitions.
With bright clients, Dr. McMahon seems to prefer starting with evaluative
cognitions and then maybe working on distortions, if necessary (I know that if
the change of irrational beliefs was not accompanied by a change in
distorted cold cognitions, Dr. McMahon would directly examine automatic
thoughts and other distortions - personal communication). I would like to see
some research evaluating concurrently these two different cognitive
strategies. I assume that their efficacy may differ depending on the clinical
condition (e.g., the type of psychopathology, the type of client).

III. DISCUSSIONS

After a short history, this paper briefly and critically presented the
fundamentals of case study methodology. We have then exemplified, by
using the case of "Dana" from our previous publications, how it can be
employed in clinical practice. We hope that the message to take home after
reading this article is clear. Case study methodology is not rigorous or less
rigorous per se. It becomes rigorous or less rigorous depending on the type of
knowledge we want to generate in order to solve specific problems. This is
true for all the research methods. The problems which case study is best fit to
solve are those related to exploratory studies (i.e., generating new theories),
to critical, and unusual cases. It is less fit to test a theory although, if
conditions for falsifiability are met, it can be implemented with this purpose
as well. When used appropriately, case study methodology is very rigorous,
comparable with any other research method. By appropriate we mean two
things: (1) adequate to the problem it is intended to solve; and (2)
implemented at high standards in terms of internal constraints and steps that
need to be followed.

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[Author Affiliation]

Daniel DAVID*

Department of Psychology, Babes-Bolyai University, Cluj-Napoca, Romania

* Corresponding author:

Email: danieldavid@psychology.ro

Copyright A.S.C.R. Press Jun 2007. Provided by ProQuest LLC. For permission to reuse this article, contact
Copyright Clearance Center

THE COMPARATIVE EFFICIENCY OF A RATIONAL-

EMOTIVE EDUCATIONAL INTERVENTION FOR
ANXIETY IN 3RD GRADE CHILDREN: AN ANALYSIS
OF RELEVANT DEVELOPMENTAL CONSTRAINTS
From:
Cognitie, Creier, Comportament
Date:
 December 1, 2006
Author:
Benga, Oana; Opre, Adrian; Cristea, Ioana-Alina
More results for:
APPLICATION OF REBT AND SELF ESTEEM publication:["Cognitie Creier
Comportament"]

http://www.highbeam.com/doc/1P3-
1204461161.html
ABSTRACT

We tested the efficiency of a rational-emotive behavioral intervention to

reduce the level of anxiety (emotional and behavioral) and remedy the
irrational thinking in children (ages 9-10). The participants were 63
schoolchildren (3 classes), boys and girls. They were initially evaluated with
the Spence Anxiety Scale (for the general and specific anxiety level) and the
CASI questionnaire (for the level of irrational beliefs). Their parents
completed the Spence Anxiety Scale (parent version). There were 3 groups
(classes): rational-emotive behavioral education (REBE), sham intervention (a
Placebo type group), no intervention. The intervention lasted for 20 sessions
and we assessed the level of irrational beliefs (CASI) and the general and
specific anxiety (Spence Anxiety Scale) before and after the intervention.
Results did not show a significant improvement of the REBE group compared
to the others, neither in measures of anxiety, nor in those of irrationality. The
level of REBE specific knowledge (tested with a knowledge questionnaire)
after the intervention was significantly higher in the REBE group than in the
other two groups. Parents' evaluations differed from children's own
evaluations: they tended to overlook the existence or frequency of anxiety
symptoms in their children. Possible implications and explanations are
discussed. Implications envisage the efficiency of REBE in reducing the
anxiety and irrational thinking of school-children and possible problems
regarding its applications in the classroom.

KEYWORDS: anxiety, children, rational-emotive behavioral education,

irrational beliefs

THEORETICAL BACKGROUND

Growing up as a child is turning out to be increasingly hard. In a world

expanding its complexity in an amazing rhythm, lots of children find
themselves having to deal with "adult" problems, such as socio-economic
problems, abuse, problems of relating to others. Their developmental
equipment (their level of cognitive, emotional and social development) is not
sufficiently advanced to keep up with the racing complexity and difficulty of
their everyday world (Vernon, 2004). It has become clear that we need to
provide children with instruments that would supplement and sometimes
compensate the abilities they have due to their developmental paths (typical
or atypical), in order to ensure their efficient adaptation to this complexity.
These instruments can be regarded as skills (emotional, cognitive) that
children might acquire from an educational intervention.
Rational-emotive and behavioral education: general principles and empirical
data for anxiety problems in children

It is generally accepted that the prevention of problems is an easier task to

tackle than the intervention in cases where the problems have already set up.
In other words, we don't have to and should not wait for the onset of clinical
or subclinical psychological problems (anxiety) to intervene. Rather we
should teach children the abilities they need to attenuate the risk of
developing these problems.

The present paper is focalized on such an intervention, namely the rational-

emotive and behavioral education (REBE), designed to provide children with
an equipment of abilities for emotional and cognitive regulation. That refers
to a rational, less distorted way of thinking instead of the irrational one that
leads to dysfunctional negative emotions, which in their turn can lead to
psychological conditions, such as anxiety or depression. REBE endorses the
principles of rational-emotive behavior therapy (REBT), initiated by Albert
Ellis at the middle of the last century, and from which it derived. These can
be synthesized as the ABC cognitive model (for a more detailed description
of these principles and the ABC model, see David, 2006). Briefly, the ABC
model states that it's not the event itself that causes our emotional states,
but our cognitions related to that event. This idea is of course not new, as it
can be traced back to Greek philosophers as Epictetus (Bernard, Ellis, &
Terjesen, 2006). "A" refers to the activating event (internal and external
stimuli). The "B" in the model represents the beliefs the person holds about
the event. There are three major categories of beliefs: descriptions,
inferences and evaluations. The ABC model focuses mainly on evaluations
and distinguishes between two key evaluation "styles": irrational and rational.
The irrational evaluations are not logical, don't have factual support in reality
(are not concordant with reality) and hinder the person from achieving
his/hers goals. The rational evaluations are their complete opposite, being
logical, concordant with reality and helping the person achieve his/hers goals.
There are 4 basic types of irrational evaluations: absolute demand ("musts"),
awfulizing, low frustration tolerance and self/others downing. Each of these
has rational counterparts. According to the ABC model, our evaluations
towards an external or internal event cause the "Cs" (emotional and
behavioral consequences). The Cs can consist of dysfunctional emotions and
behaviors, which are brought about by irrational evaluations or functional
ones, brought about by rational evaluations. While the valence of functional
and dysfunctional emotions can be the same (e.g. both are negative when
the event is the person finding out he/she has a serious illness), the
differences lie in intensity and their impact upon behavior. In contrast to
functional emotions, dysfunctional ones are more intense and prevent us
from trying to act on the situation and improve it (in the previous example,
depression would be a dysfunctional emotion, and sadness a functional one).
The basic approach of rational-emotive behavioral education is to try to
flexibilize the irrational evaluations, changing them into rational ones, thus
correcting and/or preventing dysfunctional emotions and behaviors. When
working with children and adolescents, this is not carried out directly, but
through a series of activities and follow-up discussions. Vernon (2004)
considers that, in contrast with other emotional education programs, REBE
offers its beneficiaries the "power" to assume control over their own lives.
This is achieved firstly through their understanding of the link between their
thoughts, feelings and actions. Secondly it is accomplished by the grasp that,
even though they have no means of changing the other people or events in
their lives, they can exert control over themselves, their thoughts, emotions
and behaviors.

Moreover, studies show that approximately 70% of the young people who
benefit from mental health services do so only at school, which turns the
educational system into a privileged system for offering these types of
services for young people (Farmer, Burns, Philips, Angold, & Costello, 2003;
Gonzales et al., 2004). But as the number of young people that could benefit
from such services increases, so does the need of implementing empirically
sustained interventions in schools (evidence-based interventions) (Gonzales
et al., 2004; Stoiber & Kratochwill, 2000). REBE is one such intervention, as
we see later on.

Anxiety disorders are among the most prevalent forms of psychopathology in

children. Studies with community samples showed that approximately 8-12%
of children satisfy the criteria for a form of anxiety disorder that is serious
enough to interfere with their daily functioning (Anderson, Williams, McGee, &
Silva, 1987; Costello, 1989; Spence, 1998). Anxiety problems in children are
associated with a range of negative consequences in terms of school, social
and personal adaptation (Messer & Beidel, 1994; Spence, 1998). There is
evidence showing that anxiety problems are not merely temporary problems
for children. If left untreated, they can persist in adolescence and adulthood
(Keller et al., 1992; Pfeffer, Lipkins, & Plutchik, 1988; Spence, 1998) and can
also be predictors for other clinical disorders (e.g. depression).

One of the first studies regarding rational-emotive education (REE - a form of

education which was later on enriched with behavioral elements, thus
resulting in rational-emotive behavioral education or REBE) was carried out
by Knaus and Bokor (1975). They designed a pilot study to measure the
efficiency of a REE intervention to influence children in developing a more
positive self-concept and reducing test anxiety. The results sustained the
greater efficiency of REE compared to a program of enhancing self-esteem,
but both approaches were superior to no intervention.

DiGiuseppe and Kassinove (1976) examined the effect of a REE intervention,

with a duration of 15 weeks, on the emotional regulation mechanisms of 204
students, grades 4 to 8. The experimental group was compared both to a
group that received alternative treatment and to a control group. The results
sustained the idea that rational-emotive principles could be acquired by
students and that this acquisition was considered to be conducive to a
reduction in the anxiety and neuroticism scores.

Miller (1978) compared REE with a condition combining REE with behavioral
reinforcers, another one combining REE and homework, and a control
condition. The subjects were 96 children, with low and high IQ levels. The
dependent variables were the children's knowledge, neuroticism and trait-
anxiety. The results of the three experimental groups were significantly
superior in comparison to the control group. Intelligence did not prove to
have an effect on the results (see also Silverman, McCarthy, & McGovern,
1992).

Greenwald (1985) addressed his intervention to 4th grade students, with

ages between 10 and 12 years. They were randomized in 4 groups - one
control and 3 experimental groups. These were as follows: REE, REE plus
rational-emotive and behavioral bibliotherapy, REE plus rational-emotive and
behavioral imagery. The results showed that students in the third
experimental group (REE + imagery) displayed the most significant
improvements in self-concept and rational thinking, compared to the other
groups. The reduction in anxiety was greater for the first group (REE) than for
the second one (REE + bibliotherapy). It was concluded that rational-emotive
imagery could bring additional benefits to REE (see also Silverman, McCarthy,
& McGovern, 1992).

Grassi (1985) investigated the efficiency of REE and self-instruction training

on children with medium and high anxiety, from grades 4 to 6 (36 subjects in
grade 4 and 36 in grade 6). Emotional evolution was monitored through 2
questionnaires filled in by the children, a behavior evaluation scale, filled in
by the parents, and another one completed by teachers. Compared to the
control group, both experimental groups attained the content of the two
types of training, but only the effects of REE were maintained in the follow-
up phase. They both contributed to the reduction of anxiety, but REE was
more efficient in reducing neuroticism.

Cardenal Hernaez and Diaz Morales (2000) studied the effect of three months
of REE versus relaxation techniques on self-esteem and anxiety level, in 12-
14 years old children from Spain. 93 students were randomized in the 2
experimental groups and the control group. The measures applied consisted
of the Piers-Harris self-concept scale, a body attraction scale and STAI.
Measures were carried out for pretest, posttest and at three months follow-
up. Results showed that both experimental conditions equally contributed to
the global increase in selfesteem and the reduction of anxiety.

Meta-analytical research concerning the efficiency of REBE for anxiety

problems is not consistent. Gossette and O'Brien (1993), in a metaanalysis
that took into account 33 unpublished dissertations, found an efficiency of
25%. DiGiuseppe and Bernard (1990), in a metaanalysis conducted on 23
studies, found an efficiency of 50%, whereas Hajzler and Bernard (1991),
analyzing 21 studies, found an efficiency of 80% (see also Popa, 2004).

One of the most recent meta-analysis (Gonzales & al., 2004) regarding the
efficiency of rational-emotive behavioral therapy (REBT) in a wider range of
emotional and behavioral problems (including anxiety) highlights some
important discoveries. It was carried out on 19 peer-reviewed studies and it
analyzed 5 domains of results (disruptive behavior, impropriation of
rationality, GPA -grade point average, self-concept and anxiety). Their first
and more general conclusion is that, subsequent to a REBT intervention, the
modal child or adolescent had better performances, regardless the type of
result considered, than approximately 69% of the control, no treatment
groups. But another conclusion proves very interesting and can also act as a
justification for the current study: REBT intervention seems to be efficient
both for children and adolescents with an identified clinical problem, as well
as for those without one. This motivates preventive interventions, targeting
sub-clinical problems or problems that have not yet manifested, but for which
we know the child to be vulnerable. Another important conclusion of this
meta-analysis, which contributes even more to justifying the current study,
states that the efficiency of a REBT intervention is much higher, IF it
addresses younger children (primary school) than older ones (secondary
school or high-school). Another conclusion warns about the danger of the
intervention not being effective because of its too short duration: REBT
efficiency is higher in conditions with a medium (675-770 minutes) or high
(1200-2115 minutes) duration of the intervention. Regarding anxiety, effect
sizes for these measures are presented in 6 of the 19 studies (12 effect
sizes), leading to a .48 effect size.

Developmental considerations regarding children's emotional and behavioral

problems and the implementation of REBE for these problems

As we mentioned before, many young people are not "ready",

developmentally speaking, to deal with the "adult" challenges they often
face. One of the factors contributing to this is the fact that their level of
cognitive development predisposes them to irrational thinking, in the form of:
1) suprageneralizations, 2) demandigness, 3) low frustration tolerance, 4)
awfullizing and 5) global evaluation (Vernon, 2004).

Bernard, Ellis and Terjesen (2006) express a similar opinion, drawing the
attention to the close relations that exist between children's emotional and
behavioral problems and certain developmental problems in the domain of
cognitive processing of emotional or social aspects. It becomes obvious that
any therapeutic approach of children, be it preventive or corrective, has to
take into account the fact that they are developmentally vulnerable to some
cognitive processing errors (Bernard, et al., 2006). Many of these errors are
due to the ontogenetic features of the cognitive development of 9-10 years
old children.

Typical cognitive errors (according to Bernard, et al., 2006) include: 1.

drawing arbitrary inferences (conclusions that are not based on evidence or
that contradict the evidence); 2. selective abstraction (focusing on a detail,
taken out of context, ignoring essential characteristics of the situation);

3. maximization/minimization (errors in evaluating the significance of the

event); 4. personalization (the tendency to relate external events to
themselves when there is no basis for making this connection); 5.
overgeneralization (drawing a conclusion based on limited and isolated
elements); 6. dichotomous thinking (tendency to place events in opposite
categories, e.g. good-bad).
These errors become even more poignant and can develop into dysfunctional
processing styles, when the information to be processed has an increased
emotional valence. A relevant example to sustain the idea that cognitive
development cannot be ignored in the study of emotional and behavioral
problems comes from the studies of social cognition. Research in this domain
show that family factors (e.g. exposure to problematic parental factors) that
predict adaptation problems, also predict social cognition deficits (Barahal,
Waterman, & Martin, 1981; Downey & Walker, 1989; Pettit, Dodge, & Brown,
1988; Smetana, Kelly, & Twentyman, 1984,). This suggests that social
cognition abilities could mediate the relationship between family risk factors
and child's adaptation. On the other hand, if children from high-risk families
are exposed to competent models, they can develop social cognition abilities
that can compensate the increased risk for adaptation problems, related to
parental psychopathology and abuse (Downey & Walker, 1989). Thus the
developmental level of social cognition is an important element in the
relation between the risk factors the child is exposed to and the emergence
of emotional disorders. We can notice a fairly transparent symmetry with
irrational beliefs (the Bs in the ABC model, for details about the model, see
David, 2006) and the emergence of dysfunctional negative emotions (which
by repetition can turn into a dysfunctional emotional pattern, the premise for
the development of emotional and behavioral problems, such as those from
the anxiety spectrum). An interesting research topic would envisage the
conceptual and empirical relations between these constructs (irrational
beliefs and social cognition).

One of the fundamental reasons for considering REBE as a privileged

modality to approach children's emotional and behavioral problems is the fact
that it uses a perspective consistent with that of developmental psychology.
More precisely, REBE satisfies the existent criteria for determining a theory's
developmental potential (Bernard, et al., 2006; Holmbeck & Updegrove,
1995). Among these criteria, according to Bernard, et al., (2006), we can
mention: keeping up-to-date to the most recent discoveries in developmental
literature; taking into account the critical developmental periods and tasks,
relevant for the child's problem; the flexible prioritizing of the symptoms, as
a function of the degree in which each symptom is atypical from a
developmental standpoint. In addition, REBE follows a developmental
perspective also because of its evaluation and intervention modalities, which
are projected so they would take into account the developmental level
(physical, cognitive, emotional, and social) of the child or adolescent
(Bernard & Joyce, 1984; Bernard, et al., 2006). A lot of its techniques and
activities are specific ones, developed together with educators and teachers,
who work in direct interaction with young people.

OBJECTIVES OF THE PRESENT STUDY

The main objective of the current study is the evaluation of a REBE

educational intervention in children of 9-10 years of age for emotional (e.g.
intense worry) and behavioral problems (e.g. avoidance of anxiety-inducing
stimuli) from the anxiety spectrum. Our goal is to see whether through REBE
interventions we can improve the mental (reduction of the irrationality level)
and emotional (reduction of the anxiety level) functioning in these children.
Also we attempt to clarify the efficiency and problems that can arise in
implementing a specific REBE program in the ecological context of the
classroom.

The comparative evaluation refers to determining the efficiency bonus that a

specific REBE intervention can bring over: 1) a sham intervention (where the
improvement would be caused by Placebo mechanisms, the results being due
to the mere presence of an intervention and not to the technique) and 2) no
intervention. The improvements regard the reduction of the irrationality level
and the anxiety level, measured by specific instruments.

We must mention that the study has an exploratory character. Therefore we

cannot formulate precise hypotheses, so the following are more likely
suppositions that should be taken with some degree of caution.

1. Children who benefit from the REBE intervention will present a more
significant reduction of irrationality than those who benefit from the sham or
no intervention.

2. Children who benefit from the REBE intervention will present a more
significant reduction of anxiety (global score as well as specific problem
categories) than those who benefit from the sham or no intervention.

METHOD

Subjects: Subjects were 63 children, aged between 9 and 10 years from three
3rd grade classes, selected from 2 schools in Cluj-Napoca. 36% of all children
were girls and 64 % boys. Participation in the program was voluntary and
school, teachers' and parents' agreement for the program were previously
secured. We could not in this case ensure a random selection and distribution
in groups. Even if the schools were randomly selected, in order to carry out
the intervention we depended on the availability of the school-principle,
teachers and parents. Moreover, we were interested in seeing how the
intervention works in an ecological environment, because that will be the
setting for structured mental health programs dealing with children's
emotional difficulties. To prevent some of the problems that arise from the
lack of randomized selection, we controlled for the existence of significant
differences between the 2 groups on measures of anxiety and irrational
beliefs.

Experimental design: The research method was quasi-experimental, in the

form of a pre- and posttest groups design, because we have no means of
controlling the various environmental influences the children are subjected
to, outside the limited weekly duration of the intervention. The independent
variable consisted in the type of intervention and has 3 modalities (rational-
emotive intervention, sham intervention, no intervention), which will be
detailed in the procedure section. The dependent variables circumscribed the
level of irrational beliefs, the anxiety level (both general level and specific
types) and the degree of rational-emotive knowledge following the
intervention. These were measured by specific tests and a knowledge
questionnaire.

We decided to include a sham intervention group so that, should the

intervention be efficient, we could extract some information about the
mechanisms that lead to its efficiency. This group benefited from an
intervention with the same duration and the same person as the REBE group,
children and their parents being told that the person is certified in such an
intervention. The activities and discussions had the same structure and set of
rules (non-evaluative). What differed was the content of the sessions
(astronomy - things about universe, stars, planets), constructed in such a way
that the mechanisms assumed to operate in the rational-emotive intervention
are, in as much as possible, inactive. Thus, the mentioning of people, their
emotional problems, cognitions, relationships was suppressed from the
content of the sham intervention. If this particular REBE intervention is
efficient and operates on the basis of the general mechanism presented by
the REBT theory, then it should lead to a reduction of anxiety significantly
more substantial than what could have been achieved by the mere
maturation of the subjects (check control group) or on the basis of a different
intervention, in which the REBT change mechanism is kept inactive (check
sham group).

Procedure: The testing phase was individual for all subjects. The same
instruments were used in the pre- and posttest phase (after the intervention).
The intervention phase lasted for 3-4 months, with 2 regular sessions of
about 45 minutes per week (20 sessions of actual intervention for the REBE
group and the sham group).

The REBE group benefited from an intervention structured in 4 modules:

1. Emotions (development of vocabulary and knowledge about emotions)

2. Beliefs and behaviors (understanding what beliefs are and how they
determine our emotions and behavior - the ABC model)

3. Self-acceptance (learning to accept themselves and others as imperfect

human beings, with positive and negative features, avoiding global
evaluations).

4. Problem solving (developing problem solving strategies and approaching

specific problems for anxious behavior)

The material used consisted of the book "Programul de dezvoltare a

inteligentei emotionale prin educatie rational-emotiva si comportamentala,
clasele I-IV"/ Thinking, Feeling, Behaving. An emotional education Curriculum
for Children (author Ann Vernon, translated and adapted in Romanian by
Opre, David, Baltag, & Vaida, 2004). Each session comprised an activity part
(stories, games or other activities), followed by discussions.

The sham intervention group benefited from an intervention of the same

frequency and duration and with the same person. The content however
envisaged the enrichment of the knowledge about Earth and Universe and
avoided as much as possible discussions involving animate beings (humans,
their relations, beliefs, emotions). The structure was identical to that of the
REBE group, images, texts and games were used, interactions were
encouraged, the discussions stage was present, but these were all focused on
the specific information presented. In the no intervention group, there was
only a pre- and posttest phase.

Instruments:

For measuring anxiety we used to the following instruments:

* The Spence Children' Anxiety Scale - SCAS (Spence, 1994). The scale is
composed of 38 items, 6 filler items and an open question. The child is asked
to read each statement and appreciate how often that particular thing
happens to him on a 4-point scale. The questionnaire offers a global anxiety
score, as well as scores for specific clusters of anxiety related problems.
These clusters are represented by the subscales of the SCAS: panic attack
and agoraphobia, separation anxiety, physical injuries fear, obsessive-
compulsive behavior, generalized anxiety. It is constructed following the DSM-
IV criteria, which enhances its precision in accurately identifying anxiety
problems and it is meant to be an indicator of the number and severity of
anxiety symptoms. The authors also establish cut-off points, circumscribing
three problematic categories in which the subject could be placed: at risk
(16% of the population), borderline clinical (7%), clinical (2-3%). The SCAS is
in the final stage of its adaptation for the Romanian population (Benga, 2006,
in progress), and the preliminary date indicate good reliability, both for the
global scale and for its subscales. Data from other populations (German,
Dutch) indicated very good reliability for the scale and its subscales and good
discriminate validity, using a clinical anxiety diagnosis as criterion (Spence,
1998).

* The Spence Children' Anxiety Scale (SCAS) - Parent version (Spence, 1994).
The content, cotation and interpretation are almost identical to the SCAS. It
consists of 38 items and an open question. There are fewer studies regarding
it, but the data indicate satisfactory to very good reliability for the scale and
its subscales and good discriminant validity regarding the clinical anxiety
diagnosis (except for the generalized anxiety subscale)- Nauta et al., 2004. It
is also being adapted on the Romanian population (Benga, 2006, in progress).

For measuring irrational beliefs we used:

* The Child and Adolescent Scale of Irrationality - CASI (Bernard & Laws,
1999): It is addressed to children and adolescents between 9-18 years of age
and is comprised of 28 items, formulated as statements about which the
subjects to express their agreement on a 5-point Likert scale (1- strongly
disagree, 5- strongly agree). CASI overcomes the problems presented by the
other existent irrational beliefs scales, as the theoretic model it was based on
takes into account the recent theoretical and empirical discoveries in REBT
and REBE research, and the items are exclusively cognitive ones. The scale
was adapted on Romanian population (Popa, 2006). The validation study used
factorial analysis and 4 factors were identified (consistent with the ones in
the initial validation study). These are: low tolerance to frustration brought on
by rules, global evaluation of the self, demands for fairness, low tolerance to
frustration brought on by work (Popa, 2006). The scale has good global
fidelity (α Cronbach= 0.84) and its subscales have satisfactory to good
fidelity (Popa, 2006).

We also resorted to an evaluation of the knowledge attained subsequently to

the rational-emotive behavioral intervention by means of a knowledge
questionnaire. This comprised of 20 questions, formulated from the content
of the REBE lessons and it was administrated to all 3 groups. We wanted to
see whether there were any significant differences after the intervention in
the level of declarative knowledge between the 3 groups, in other words to
see whether or not at least declaratively (even if that doesn't express in a
reduction of anxiety or irrational beliefs), the REBE group has attained data
that has not been acquired by the other groups.

RESULTS

Descriptive data

In the table above, we display the means and standard deviations for the
anxiety measures (pre and post-test).

If we compare these scores to the normative values (from validation studies

carried out on other populations), we can see that for the REBE group, the
pretest mean values for separation anxiety (cut-off points: 7-9), physical
injuries fears (cutoff points: 5-6), as well as global anxiety (cut-off points: 40 -
51), can be placed in the at risk category for clinical anxiety problems
(according to the cut-off values previously described). Also the pretest mean
value for obsessive compulsive behavior for this group can be located in the
borderline clinical domain (cut-off points: 11-12). For the sham group, none
of the pretest mean values can be located in the at risk, borderline clinical or
clinical spheres. For the control group, only the pretest mean values for
physical injuries fears (cut-off points: 5-6) and obsessive compulsive behavior
(cut-off point: 10) can be located in the at risk area. None of the posttest
mean values, for any of the three groups, can be located in the at risk,
borderline clinical or clinical domains. Where more than one value is
displayed for cut-off points, it is because the values are different for boys and
girls.

In table 2, we present the measures for irrational beliefs. As the normative

values reported in the initial validation study (Popa, 2006) are general ones
for young people with ages between 9 and 17 years, we didn't view them
reliable enough for reporting the mean values we obtained to them. It is clear
that, given the developmental differences among children of these ages, the
normative values for high and very high irrationality cannot be indifferent to
age.

Intra-group comparisons
We used the t test for paired samples. Significant values are marked with an
asterisk (p<.01). We chose an alpha threshold of .01 (even though the
commonly accepted value for alpha in psychology research is .05), because
in this case we wanted to keep the type I error as small as possible. An
educational intervention as the one employed here requires a significant
quantity of resources (time, materials, human resources) and we have to be
sure about its efficiency before engaging all these resources to implement it.
Therefore, we have to be more strict in assessing its efficiency and should
recommend its implementation only on the basis of a clearly distinguishable
effect. So we chose a lower alpha threshold than it is usually accepted in
order to prevent false positives (finding a significant effect when in fact there
is none) as much as possible.

We can see that the effect of the intervention in each group concerning
irrational beliefs is practically insignificant. Regarding the anxiety level, we
must first notice that the REBE group displays significant improvements on
the panic attack and agoraphobia subscale, improvements that are not
present in the other groups. An interesting result is that both the REBE group
and the sham group show significant improvements on the measures of
generalized anxiety. Also both the REBE group and the control group show
significant improvements on the obsessive compulsive disorder subscale.
However the most important result for the present study involves the level of
specific REBE knowledge, which has significantly improved only in the REBE
group.

Inter-groups comparisons

We must note that in the pretest phase the differences among the 3 groups
are not significant at p<.01 for irrationality (F=2.66) and anxiety (F=4.93)
both as global scores and subscale scores. However, we must acknowledge
that the means of the REBE group (for anxiety) are consistently higher
(although not significantly so) than those in the other groups, which was also
an ethical consideration that oriented us to using that particular group as the
target group. At posttest, there are still no significant differences at p<.01
among the 3 groups for anxiety (F=3.67) or irrationality (value for F=0.53).
For a more precise assessment of the potential change we also compared
effect sizes (the magnitude of change) for each group. In this case we again
had no significant differences among the groups at p<.01 on measures of
anxiety (F=0.51) or irrationality (F=2.54). All the above, correlated with the
intra-group comparison data, allow us to conclude that in the particular case
of these classes of students, the REBE intervention did not have a significant,
consistent, transparent effect on irrationality and anxiety. However, when we
look at the data regarding the REBE knowledge, we notice that at posttest
they are significantly different in the REBE group from the sham group
(F=3.70, p<.01) and the no intervention group (F=5.26, p<.01). Moreover,
the REBE group has significantly better knowledge than the other 2 when we
look at the magnitude of change (F=5.78, for comparison to the sham group
and respectively F=5.81 to the control group, p<.01).

Data from parents

A number of 42 parents from all three groups completed the parent version
of the Spence scale (at pretest). We computed Spearman correlation
coefficients for the evaluations of parents and those of their children. The
parents' evaluation of the anxiety problems of their children and the
children's own evaluations differ in the sense that the parents tend to
overlook the existence or severity of anxiety problems. We have found
positive medium correlations at the subscales of separation anxiety
(r=0.463, p<.01) and physical injuries fears (r=0.488, p<.01). The
correlations for global anxiety and the other anxiety subscales were not
significant at p<.01.

DISCUSSIONS

Intra-group comparisons

Regarding the intra-group comparisons for irrational beliefs, the significant

result at the demand for fairness subscale in the control group could be
accounted for by the evolution of subjects, but more likely by procedural
aspects regarding the problematic application of the CASI questionnaire
with children this age (will be detailed in the limits section) or social
desirability (children remembered having filled in the scale before and feel
they are expected to offer different answers, even though in this case they
were specifically instructed that the second application has nothing to do
with the first). Regarding anxiety, the REBE group displays significant
improvements on the panic attack and agoraphobia subscale, improvements
that are not present in the other groups. However, we should be very careful
before asserting a specific effect of this intervention on this problem
category. We should first look at the inter-groups comparisons to see if there
really is a consistent effect of the intervention, which cannot be accounted
through other mechanisms (maturation, procedural aspects). We must also
mention that for this subscale, the initial mean values were very low (even
much more so for the sham and control groups), so the significant difference
can be an epiphenomenon of these small means, reported to which any small
change can count. Both the REBE and the sham group show significant
improvements on the measures of generalized anxiety. A possible
explanation could be that, for children this age, a big part of the generalized
anxiety problems are generated by school pressure, evaluation, friendship or
competitive relations with peers. Both the REBT and the sham intervention
indirectly approach these problems by using activities in which children are
not evaluated, trying to get everyone involved, making them work in groups.
Another possible explanation is procedural and refers to the fact that the
items measuring generalized anxiety are more general and vague (e.g. I feel
scared), so they could be interpreted differently by children in different
moments, which could partly explain the fluctuation of answers. Also both
the REBE group and the control group show significant improvements on the
obsessive compulsive disorder subscale. The differences could be due to the
natural evolution of the subjects (maturation). Another explanation could be
a procedural one: the items for obssesive compulsive behavior on the Spence
scale are more difficult to understand for the child (e.g. "I have to think of
special thoughts to stop bad things from happening (like numbers or
words)"). It might be that at posttest they are more familiar with them and
with the way they should be interpreted and so their answers would reflect
reality more accurately. The fact that there is a significant increase in the
level of REBE knowledge only in the REBE group can allow us to safely
assume that, at least at a declarative level, the children in the REBE group
have impropriated some of the specific knowledge, even more so as this
process seems to be absent in the other groups.

Efficiency of the program (intra-group and inter-groups comparisons)

Starting off from this data, we came up with 2 major interpretative ways: a
procedural perspective and a developmental perspective.

From a procedural perspective, explanations should be searched in problems

specific to working in a classroom, which can be confounding variables and
could account for these results. The context is an ecological one and can offer
an accurate image of the way such an intervention could really work, in an
educational program implemented in school (increased external validity). But
problems arise with regard to the internal validity, due to the fact that we
can't exclude the distorting influence of other variables than those of
interest. Many studies have discussed the role of parents' and teachers'
irrational beliefs in inducing and reinforcing an irrational thinking style in the
child (Bernard, Ellis, & Terjesen, 2006). Parents and their behaviors may have
a double role, both as models and reinforcers. Their action could go in the
opposite direction to the REBE intervention. We tried to diminish this source
of error by explaining to the parents, in a preliminary meeting, that they
should not contradict and instead try to encourage the new ideas and
behaviors the child acquires from the intervention. Still, we can't exclude the
fact that some of them have acted, consciously or not, in the opposite
direction of our intervention. A frequently documented example is that of
perfectionism: the child is taught that he/she can't possibly do things
perfectly and that's it's not sound to ask that from himself. A better version is
for him to try as much as he can to do everything very well, but without
thinking that a potential failure would make him a worse human-being.
However, many parents demand perfection from their children and punish
them if they don't succeed in doing everything perfectly (for example always
get the highest grades, at all subjects) (Bernard, et al., 2006). It is also
evident that the parents' influence on their children is much greater than any
influence we would hope to achieve in weekly sessions, during a few months.

The teachers could represent another source of error, similar in its action
mechanism. They too have got more time with the children and more control
and reinforcement possibilities to make their influence more consistent than
that of the intervention. We tried to control this problem since the teacher of
the REBE group had attended REBE training. Still, she was present during all
the sessions, although we specifically requested her not to intervene. It is
however possible that her presence could have acted as an inhibitor for the
adequate involvement of children in the proposed activities (especially those
that required personal examples).
Still, procedural aspects are not by themselves enough to explain our results.
The activities used were taken from a manual and were specifically conceived
for group work. We need to consider explanations at a deeper level; therefore
it would be useful for us to look at the developmental characteristics of the
children involved in this program. So the second perspective for data
interpretation is a developmental perspective. We will start off from the
observation that in the REBE group, although there is no effect in the
direction of ameliorating anxiety and irrational beliefs, there is a significant
and consistent effect on REBE knowledge. Children seem to have acquired
the knowledge being discussed, but this doesn't seem to impact their way of
thinking and their emotional problems.

The main objective of our intervention referred to the fact that, subsequently
to the activities and discussions, children would extract ideas about certain
concepts (emotions, beliefs, behaviors) and then generalize and apply these
concepts in their daily lives. However, as we have pointed out in the
theoretical part, their cognitive development is impinged on by some typical
processing errors (Bernard, et al., 2006). It may be that, in the context of this
intervention, all these translated into a limited capacity of transferring the
acquired information in real life situations, especially when dealing with
emotionally loaded content. For example a cognitive error such as that of
selective abstraction (focusing on details and ignoring essential features of
the situation) (Bernard, et al., 2006) could lead children to see the activities
used as simple games, without extracting general principles (which was the
real purpose of the activity). Even in the cases when they did extract some
regularity, another cognitive error specific to their point of cognitive
development is the situated, localized nature of their inferences and concept
application (a concept's area of application is circumscribed to the context
it was learned in). In other words, it could be that what is learned in the
classroom is only applied in the classroom and not transferred to other life
situations (e.g. family problems, problems with peers). These issues could be
even more significant as the similarities between contexts (class situation -
other life situations) are not really transparent to children. The problem
situations that are outside the actual intervention sessions may not
automatically activate the idea of applying the learned concepts. Even
though they have the declarative knowledge, it is possible that children
cannot explore the benefits of this knowledge because of their
developmental particularities. A mental health educational program should
take these issues into account.

An additional observation should also be made. It regards the specific action

mechanisms of rational-emotive education: the modifications of irrational
cognitions lead to the correction of dysfunctional emotions. The present
research does not offer enough data to extract inferences about the validity
and applicability of this mechanism in the case of anxiety. Anxiety problems
in children this age have, as we have previously said, a resilient behavioral
component (Keller et al., 1992; Spence, 1998). It could be that a general
action mechanism, such as the one postulated by the REBT theory, may not
be sufficiently efficient in the case of anxiety. Intervention might have to be
specifically targeted on the particular aspects of anxiety behaviors.
Data from parents

The results are consistent with other data obtained using the Spence scales
with other populations. Nauta et al. (2004) indicate inter-correlations in the
range of 0.41-0.66 in the group of children with diagnosed anxiety disorders
and in the range of 0.23-0.60 in the group without diagnosed anxiety
disorders (our results fit in that range). The highest degree of agreement is
met for subscales that envisage behaviors easily observable (Nauta et al.,
2004). In our case, the significant, positive correlations were medium sized
and obtained in the cases of separation anxiety and physical injuries fears,
which enclose observable behaviors.

A series of studies from other domains, such as temperament research, raise

the issues of the credibility and accuracy of parental evaluations. Studies
reveal the different biases and errors that can mark the parental evaluations:
in their answers parents project the image they have constructed about the
child and his/her actual behaviors (Benga, 2002); they don't understand the
items or the instructions; they don't know the child's behaviors and their
significance; their recollections can lack accuracy (Benga, 2002; Rothbart,
Chew, & Gartstein, 2001); they want to offer socially desirable answers. All of
these can be possible explanations for the reduced correlations between the
parents' evaluations and the child's selfevaluations in the current research.

Other possible reasons have to do with the specificity of some clusters of

problems. The anxiety problems for which the evaluations are more
concordant are separation anxiety and fears of physical injuries. These
include behaviors that are more easily observable, more frequent and upon
which parents are used to direct their attention (e.g. "my child is scared of
dogs", "my child is scared if (s)he has to sleep on his/her own"). Moreover,
these are behaviors that are usually verbalized or clearly expressed by the
child (e.g. cries, yells, verbally protests to sleeping alone). However, parents
are less equipped in noticing problem behaviors of a different nature (social
phobia, obsessive-compulsive behavior). These are much less transparent
and less frequently verbalized by the child because it is often difficult for
him/her to identify the source of the problem or he/she simply does not
perceive them as problems (e.g. a child who often repeats a number or
phrase to him in order to prevent bad things might not see it as a problem).

Also we cannot omit the sociological explanation, which is the fact that
parents spend less and less time with their children and thus don't have
sufficient time to observe such problem behaviors. Actually the parents
expressed this point in the preliminary discussions (e.g. "I barely see my
child, I don't now what he does most of the time").

IMPLICATIONS FOR FUTURE RESEARCH

Based on the data obtained and the analysis carried out, possible future
research could approach:

* The modalities through which cognitive development particularities of

children of different ages can be approached in educational programs for
mental health and how this can enhance the efficiency of these programs
(through the generalization and transfer of knowledge by children).

* The identification of specific mechanisms that operate in determining

anxiety problems in children (especially discovering the mechanisms that
come into action before these problems achieve clinical intensity) and how
we can counteract these in preventive interventions.

* The development and adaptation of instruments of evaluating children's

irrational beliefs, instruments with items that are more comprehensible and
adequate for the particular age group.

Regarding the limitations, the first one refers to the lack of randomized
selection and distribution of subjects. We detailed this in the methodology
section, so we will not dwell on it again. Another limitation, resulting from
this, is the fact that the anxiety means of the REBE group are consistently
higher (although not significantly so) than those in the other groups. This
could also have been a factor influencing the results of the intervention. We
will also detail another important limitation which refers to the CASI and its
adaptation on the Romanian population. We chose this scale because, among
the ones that measure irrational beliefs, it is the most robust one
(theoretically and empirically). However we can't ignore the problems
presented by the Romanian version of the CASI, especially with children this
age. These could have seriously impaired the results. In brief, some of the
problems are: the use of a 5-point scale, as it is hard for children to operate
with these distinctions and they usually go for the extreme values;
negatively-worded items, that are difficult to interpret and the children have
to resort to complicated logical deductions about denying a negative
statement; the use of some terms that are hard to understand or vague, such
as "frustrated", "desperate"; the lack of age differentiated norms.

The present research raises more questions than it gives answers. But if we
were to quote Einstein "formulating a problem is often more important than
solving it". This research cannot offer clear and definitive answers on the
ecological efficiency of REBE in reducing anxiety in 9 to 10 years old children.
Yet we hope to have been able to provide some empirical data and
interpretations that can contribute to a more exact formulating of the
problem.

ACKNOWLEDGMENTS

This research was supported by CEEX-M1 Grant no. 124 (AnxNeuroCog) from
the Romanian Ministry of Education and Research.

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[Author Affiliation]

Ioana-Alina CRISTEA*, Oana BENGA, Adrian OPRE

Department of Psychology, Babes-Bolyai University, Cluj-Napoca, Romania

* Corresponding author:

E-mail: ioana.alina.cristea@gmail.com

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