REBT for Depression in Teens

Abstract

REBT is an evidence-based approach that helps people manage cognitive, emotional, and behavioral disturbances in sustainable, healthy ways. It takes a holistic view of emotional disturbances, including depression. In keeping with the concept of psychological interactionism, REBT views depression as a thinking-feeling-behaving pattern and not a diagnostic label alone.

Depressive thinking-feeling-behaving is a common consequence in teens in response to such adversities and can manifest in different ways. Some may want to resign to their fate and let others make these choices for them, some may want to gain more control by trying to make perfect choices, and some may want to escape the conflict by hurting themselves, overly consuming online content, binge eating junk food, and so on, and others may want to rebel and make extreme choices. Most of these ways prove to be short-term ways of coping with or managing these challenges and may be in fact harmful in the long term. REBT argues that therapy can teach teenagers to identify, practice, and internalize healthy, long-term ways of coping which they can eventually use independently across different situational contexts.

Introduction

REBT is a holistic, evidence-based approach that helps people manage cognitive, emotional, and behavioral disturbances in sustainable and healthy ways. ¹ Dr. Albert Ellis in 1955 developed REBT, a transdiagnostic model to understand what underpins human emotional-behavioral problems and to help clients proactively practice alternative, healthier ways of thinking-feeling-behaving. ² REBT can potentially help people not only cope with existing disturbances but also work preventively. In addition, it helps people work towards developmental goals. REBT takes a holistic view of emotional disturbances, including depression. Depression is not a unitary condition. It has biological, genetic, psychological as well as socio-cultural and environmental aspects underpinning it.^3–6 In keeping with the concept of psychological interactionism, REBT views depression as a thinking-feeling-behaving pattern and not a diagnostic label alone.

Some of the common themes underpinning this thinking-feeling-behaving pattern of depression in teens are―what if I am disapproved of by my friends? Am I good enough as I am? How well am I doing as compared to others? Am I too ordinary to stand out? What’s my future going to be like? and so on. They feel conflicted about different choices

Whether to be yourself or to conform to the norms

Whether to take risks or to make safe choices

Whether to strive to be independent or to look for security in your comfort zone

Whether to comply with your parent’s expectations of you or to set your own goals.

Different people respond to these conflicts with different emotions like anxiety, anger, shame, and so on. Depressive thinking-feeling-behaving is a common consequence in teens in response to such adversities. This could manifest in different ways. Some may want to resign to their fate and let others make these choices for them, some may want to gain more control by trying to make perfect choices, and some may want to escape the conflict by hurting themselves, overly consuming online content, binge eating junk, and so on and some others may want to rebel and make extreme choices. ⁷ Most of these ways prove to be short-term ways of coping with or managing these challenges and may be in fact harmful in the long term. ³ REBT argues that therapy can teach teenagers to identify, practice, and internalize healthy, long-term ways of coping which they can eventually use independently across different situational contexts. ⁸

The purpose of this article is to present a viewpoint about the specific context and cognitive-emotional underpinnings of depression in teens using the REBT model and discuss some intervention strategies and considerations from the REBT perspective.

REBT for Teenagers with Depression

REBT is a transdiagnostic theory. As the word suggests, the model remains the same across different diagnoses. ⁹ Having said that, what makes our work as therapists unique with each client is that it is based on an understanding and empathy of their personal domain. From this point of view, the inferential themes underpinning emotional-behavioral responses are very important. The client presents a problem or adversity in a therapy session. Adversity occurs when something of high value to this client in their personal domain, is being blocked. The adversity does not singularly cause the depressive emotion and behavior but plays a huge role in initiating, sustaining, and exacerbating their depressive pattern. Hence, it’s important to understand this adversity that’s blocking them. Adversity comprises not just the situation that occurred, but also the inferences or meanings that the client attached to that situation. These inferences are called the Critical A (adversity) in REBT. ¹⁰ According to Dryden, ¹¹ the inferential themes that commonly underpin the depressive pattern are:

– Loss

– Lack

– Failure

– Unfairness

– Undeserved plight

In addition to the above themes, it might be helpful to look at whether the client’s inferential theme is from an autonomous realm or a sociotropic one.

A person who values autonomy, who values freedom, independence, and individual identity is likely to feel depressed when they experience loss/lack/failure in these aspects. ⁵ For example, if they find themselves dependent on others for some of their wants or if they aren’t allowed the choice to make their own decisions they’re likely to feel depressed about it.

Adolescence is a period when teens really struggle between finding their own identity, making certain independent choices, being independent, making their own mistakes on one hand and at the same time, wanting a safety and security net around them. It’s possible that they are conflicted about which way to go, whether to take risks and make their own mistakes, or whether to keep using the safety net because they believe that they should not make mistakes. Now, if this teen is taught that mistakes have dire consequences and therefore you absolutely should not make them, then that’s going to inform this person’s choices going forward. They’re likely to develop some rigid conditions around it and feel depressed when they are not met. ¹²

On the other hand, the sociotropic realm consists of disapproval, rejection, criticism, people’s perception, and evaluation of oneself, what one can and cannot get from social interactions, and so on. Approval, acceptance, and positive evaluations can provide a safety net to teens that encourage them to take some risks and make some difficult choices. When deprived of this safety net, children could become resigned and hopeless and conclude that they have no influence to overcome life’s adversities. ⁵

In therapeutic assessment, it’s important to help the client identify the inferential themes underpinning their disturbance. As a consequence of holding these inferences, the depressive feeling experienced by the client will also be manifested in the form of behaviors. It’s helpful to assess these behavioral consequences too to understand the disturbance holistically. Some behavioral consequences are:

Withdrawing from reinforcements.

Withdrawing into oneself (particularly in autonomous depression).

Becoming overly dependent on and seeking to cling to others (particularly in sociotropic depression).

Bemoaning one’s fate or that of others to anyone who will listen (particularly in pity-based depression).

Creating an environment consistent with your depressed feelings.

Attempting to terminate feelings of depression in a self-destructive way.

In addition to the emotional experience and these behaviors, clients are likely to create some more inferences as cognitive consequences. ⁴

• Seeing only negative aspects of the loss, failure, or undeserved plight.

• Thinking of other losses, failures, and undeserved plights that self/others have experienced.

• Ruminating about the source of depression and its consequences

• Thinking one is unable to help oneself (helplessness).

• Seeing only pain and blackness in the future (hopelessness).

• Seeing oneself as being dependent on others (in autonomous depression).

• Seeing oneself as being disconnected from others (in sociotropic depression).

• Seeing the world as full of undeservingness and unfairness (in plight-based depression).

REBT argues that there are four basic attitudes/beliefs underpinning most human emotional-behavioral disturbance. ¹⁰

• The rigid attitude, for example, I want to be approved by my peers and so I absolutely MUST be

  The derivatives or extreme attitudes –

• Awfulizing: It’s not only bad when I do badly in exams but it’s awful and horrible.

• Frustration or discomfort intolerance: It’s very difficult to tolerate being rejected and therefore I can’t stand it at all.

• Global rating of self, others, or life: If I fail at per-forming well, it proves that I am a failure and therefore worthless as a person.

The entire ABC model is anchored to the client’s goal in therapy. It’s especially important to spend time with teenagers on identifying and committing to a clear and concrete goal. It can seem harder to do that in a depressive state of mind that is tilting towards hopelessness. If the therapist spends time and energy in the process of setting and reassessing goals throughout the therapeutic interaction, it increases the probability of developing and implementing appropriate intervention strategies toward their specific goals.

REBT employs a vast array of cognitive, emotive, and behavioral techniques to help clients implement and sustain changes in their depressive thinking-feeling-behaving pattern. It can help them cognitively examine their harmful rigid and extreme attitudes and move toward flexible and non-extreme attitudes. For example,

Flexible B - I strongly want to be approved by my peers, but sadly it doesn’t follow that I absolutely must be approved.

Non-awfulizing B - It’ll be bad if I do badly in an exam, but not awful or horrible. It’s not the worst thing ever and is not irreparable.

Frustration/Discomfort tolerance B - It is very difficult to tolerate when I get rejected, but I choose to and I can stand it because it’s worth it for me to do so.

Unconditional self-acceptance B - If I fail at performing well, it does not prove that I am a failure or a worthless person. I accept myself as a fallible, complex human being who is capable of failure.

Certain emotive-behavioral techniques are likely to work better with teenagers such as rational-emotive imagery, fixed role play, time projection, using metaphors and analogies, and in vivo exposure techniques among others.

Case Discussion

A 14 year old came to therapy with the presenting symptoms of low, depressed mood, withdrawal from social interaction and thoughts of self-harm over 2-3 months. The situational context was that her group of close friends in school abandoned her for a mistake she made. They started avoiding and ignoring her despite her efforts to apologize and make up. A detailed problem assessment showed that her problem could be conceptualized as follows:

Critical adversity - I have failed to keep my friends’ trust.

Basic attitudes - I must never fail to keep my friends’ trust and live up to their expectations.

Since I have failed to do so, it proves that I am worthless and deserve to be punished by them.

Emotional consequences - depression, self-blame.

Behavioral consequences

Withdrawing from reinforcements.

Withdrawing into herself.

Creating an environment consistent with her depressed feelings.

Attempting to terminate feelings of depression in self-destructive ways.

Cognitive consequences

Seeing only negative aspects of the loss

Ruminating about the source of depression and its consequences

Thinking one is unable to help oneself (helplessness).

Seeing only pain and blackness in the future (hopelessness).

Seeing herself as being disconnected from others.

Once she learnt the ABC model of emotional responsibility, she was able to see that she could change her feelings of depression even if her friends didn’t accept her. As an intervention, it helped her to learn to accept herself as a fallible, complex person who unfortunately is capable of making mistakes sometimes. Once she practiced and internalized this new attitude using various emotive techniques, she didn’t feel the need to punish herself in any way. Eventually, she took steps towards making new friends while refusing to devalue herself based on how her friends treated her.

In conclusion, it is vital to have a mindfully assessed and elaborate problem conceptualization based on the REBT model. Using this to create a customized repertoire of intervention techniques that can be consistently rehearsed by the client can prove to be an effective method to help teens manage their depressive thinking-feeling-behaving patterns.

Some anticipated obstacles to change can be:

– Because my thinking is emotionally compelling, therefore it must be true.

– I need motivation, mood, and certainty as prerequisites for action.

– Taking responsibility for one’s depression means self-blame.

– I can’t do anything to help myself.

– I am entitled to do some self-pitying and wallowing.

– I will lose some benefits that staying depressed gives me.

– If I stop being depressed, it’ll prove that I had no reason to. Hence my feelings will be invalidated.

– If I ask for help/show my vulnerability, it will prove that I am weak.

It can be helpful if therapists can learn to anticipate these obstacles, recognize them in time and be trained to help the clients overcome them.

Future Considerations

An important question that we need to try and answer as a society is “what are the most effective ways to equip these young people with skills and tools that help them resolve conflicts, face and overcome challenges when they can and keep making helpful choices at critical points in their life?”

In my opinion, therapeutic and developmental interventions need to become a default part of the ecosystem of a teenager’s life. Can schools and colleges encourage every student to interact with a counsellor? Can parents encourage their kids to focus on mental fitness as much as physical fitness? For example, going to a mental fitness workshop twice or thrice a week just like you would go to the gym or a yoga class, doing daily homework/practice to enhance mental health just like you would do daily school homework, actively teaching mental hygiene just like one would teach physical hygiene.

If working towards a healthier mind becomes a seamless part of a teenager’s life, we could build a strongfoundation that works towards preventing psychological disturbances as these teens move forward in their lives. Asking for help with emotional-behavioral problems can cease to be a stigmatized, shameful thing. But this needs to be preceded by a radical shift in our attitudes towards mental health as adults, caregivers, and guardians of society. Are we willing to come out of our comfort zones first? Are we willing to be vulnerable first, before we can encourage our children to do so?