REBT Conceptualization of a Case of Depression

Hello everybody. I am Dr. Steve Johnson, and today I will be covering the REBT case conceptualization of an individual with depression. This is a follow-up of two lectures that I've done for Gift University in Pakistan, in which I've covered an introduction to REBT, and then in the second lecture, I looked at the conceptualization of emotions within REBT. And we noticed that there was some confusion among some individuals, and this is quite normal, about the difference between inference and belief. And so today, I will kind of summarize, using an example of an actual case. It's a made-up case, but we will walk through it using the information that I have covered in those two lectures. So let me just pull up the PowerPoint, and we will, um, we will begin.

Okay, so, um, let's see here. So as you can see here from the beginning, this is a case conceptualization of a case of depression. So let me cover this, um, this case quite, quite briefly. And, um, you may want to take notes as we're doing this, and then I'll walk you through the, um, I'll walk you through the case, uh, and the analysis of that in just a few minutes.

Juan is a 48-year-old male who's married and has three children. Three months ago, his wife told him that she would like a divorce. Initially, Juan was angry with his wife, but in the last month, he has been waking up in the middle of the night and has trouble returning to sleep. He's eating very little, his energy level is low, he's been drinking more than he normally does, and he hasn't been interacting with his children or his friends as much as he typically does. He's consistently feeling guilty, and at work, he, uh, has trouble focusing on anything but the upcoming divorce or the announcement of that divorce. And he reports that he's feeling quite hopeless about it. However, he denies any suicidal ideation or plans. When asked by his therapist what emotion he was experiencing, he says that he's very depressed.

Okay, let's get, let's continue with the case. And that is when the therapeutic, at therapists, ask Juan what he's thinking when he's ruminating on the upcoming divorce, he says that if his wife does indeed divorce him, that this will be the biggest loss he's experienced in his life. He further says that he's Roman Catholic, and that his wife must not divorce him, and that if she does, it will be absolutely horrible for him, as well as the children. He says that often he thinks that he's been a failure as a husband, and this, he thinks, negatively impacts his children. When asked about his drinking and how much he drinks, he says, "I know I shouldn't, but this is all too much for me to deal with. I'm too weak to handle it. This, it is huge." When asked about his goal in therapy, he said, "I want to be happy again."

So let's use the analysis first using the ABC model, and then we'll shift over to amplifying this with a discussion of the complete conceptualization of emotion as covered within REBT. So here, we, we're asking in the ABC model, what is the A, what is the activating event, or in this case, the critical activating event? Well, he, um, the clearly the critical activating event is that his wife has told him that she wants a divorce.

If we skip over the B, the beliefs, and go to the consequences in the ABC model, and we look, and remember this, the consequences are the emotions, behaviors, and physiological responses. We can say that that the dysfunctional negative emotions in this particular case would be depression and guilt. And some of you may say, well, he was also angry, but at the point he's coming in, and the emotion he is reporting now is depression, not anger. However, we don't get it in this case, but if we were, if we were an REBT therapist and Juan was our client, we would want to check whether he's generally depressed about what his wife said, or whether the depression is about being angry. Right? And so if the depression was about being angry, then the depression would be a secondary symptom. But we get no hint within this case that his depression is about being angry, but moreover, that the depression is about the fact that his wife has announced that she wants a, uh, divorce.

The dysfunctional behaviors, there's a number of courses, um, drinking alcohol has increased, his eating has decreased, he's not engaging, um, in interactions with his friends and the children, he's spending a good amount of time, uh, ruminating. And then of course, there are a good number of physiological responses going on here too. So we see that he is clearly dysfunctional in that emotion. If we were asked to ask him in what ways his depression is interfering, we already get a hint that it is causing some trouble on the job because he's spending his time ruminating about, um, the purported upcoming divorce.

Well, what are his, um, irrational beliefs? Now, um, I didn't ask right here, but we could include among the irrational beliefs both inferences and beliefs. And remember the difference between an inference and a belief. The inference, these are both cognitions, but the inference is the type of cognition that will attribute meaning to the situation. Here, the meaning that he's giving to the fact that his wife says that she wants divorce. And then the beliefs would be the evaluations that he has about what his wife just said. So the inference here will be that the divorce will be a big loss, and that is what he said. So that is the meaning that he's giving to this.

The beliefs are, and we remember there are four categories of beliefs: demandingness, awfulizing or catastrophizing, frustration intolerance, and global negative evaluation of self, others, life, and world. And so if we look particularly at the beliefs he has right here, right now, about the fact that his wife is saying that she wants a divorce, then, um, we, uh, we see a series of beliefs: one, that, um, that his wife must not divorce him, and then of course, also that he shouldn't be drinking as much as he is. The, uh, awfulizing or the catastrophizing is that it would be horrible if his wife divorced him, and that it is absolutely huge. And the frustration intolerance is that the divorce is too much, it's even too much for him to think about it. Global negative evaluation is the global negative evaluation of the self, is that he is a failure as a father, that he's very weak, and then that this, that his life right now is pretty hopeless. Um, and by the way, many people would say that being hopeless or helpless would be an emotion. These are actually thoughts, and when they, an individual has a thought of being helpless or thinks about being hopeless, then they often have resultant emotions as associated with that.

So this is the analysis of the, of the ABC. So let's shift to the conceptualization of emotion. And remember that the conceptualization of the emotion involves accurately identifying the following. And the, the following would be the inferences that the individual has, the general type of inference, but also we need to specify, uh, exactly what the inference is that the client is voicing or holding. And then the beliefs, not the hypothesized beliefs, but those specifically stated by the client. Don't run with your hypothesis, form a hypothesis, but you can't say that that's the belief unless it is confirmed in the conversation with the client. And then the other part of the conceptualization is the action or behavioral potential associated with that dysfunctional emotion. And for all of these things, we don't run with our hypothesis, we have to get exactly from the client what is going on.

So let's go to the inference. What is the general type of inference? Well, the emotion is, is depression, and the general type of inference that we see with depression is that the client is inferring that they are experiencing a significant loss. And a significant loss in this case would be the loss of the marriage resulting from the depression. The specific loss, we just said that it would be the, um, the divorce.

The beliefs, we've already, um, uh, uh, uh, uh, specified. Let me just actually flesh out that inference a little bit more specifically for the client. The, the, the inference is that the divorce is the biggest loss that he has experienced in his life up to this point. So, um, that is the exact statement of the inference. Now, the beliefs, we've just, we just gave, um, we just covered the demandingness, the awfulizing, the frustration intolerance, and the global negative evaluation.

Now, what is the action or behavioral potential? Well, we know generally in the conceptualization of emotion that the action or behavioral potential of, of depression is withdrawal. Withdrawal from others, withdrawal from things that are normally experienced as positive, etc. In this case, he very clearly says that he is withdrawing from connection with his children and his friends. So that would be, uh, pretty much what we would see in a case of, of depression.

Okay, now when we go to the conceptualization of the emotion, part of what we're doing here is we've just looked at the dysfunctional inferences, beliefs, and action potential. And now we want to know what would be the functional alternative, although negative emotion. What would be the functional alternative negative emotion to the dysfunctional negative emotion currently experienced by the client? Well, the dysfunctional negative emotion currently experienced by Juan is depression. So what we need to consider is the functional alternative negative emotion, which generally in REBT, we would say is sadness.

What would be the inference for sadness? Well, the inference for the functional negative emotion is going to be exactly the same as it is for the dysfunctional negative emotion. And since the inference was that the divorce is the biggest loss that he's ever experienced in his life, that's going to be the inference for his sadness. If we get him to the level of sadness in our treatment, what would be the beliefs for the functional alternative, uh, emotion? Well, uh, let's just go through these and let's take them by category. For demandingness, the functional alternative belief would be, "Yeah, I, I hope my wife doesn't divorce me, but, you know, I don't want that at all. But there, you know, she may do it. And, um, there's nothing in the universe that says that she, that she can do it. She has free will, and she's certainly capable of, uh, of doing that. I wouldn't like it. I prefer that she not. I hope and wish and want and all of those things that she, uh, doesn't, but there's no reason that she absolutely must not do it." So that would be a functional alternative negative belief to the demandingness.

What about the functional alternative belief to awfulizing? Instead of believing that it would be, and ongoingly thinking about, um, that it would be horrible that his wife divorces him, he may believe that it is horrible. But the awfulizing that is dysfunctional is to continually ruminate on that over time. So what would we want is to decrease the frequency of, of, uh, thinking about that and eventually, uh, maybe not believe that it would be terribly horrible and awful in the sense of negating all meaning, purpose, and potential happiness in life. But immediately after, um, hearing that, he is going to believe that it's awful, and it would be. So in that case, what we would want is to work on frustration, uh, intolerance about that. So let's get to that. The, um, is, um, the frustration intolerance, we would like to switch to frustration tolerance. In, in this case, that would be the functional alternative would be, um, the divorce would be a lot, and there would be maybe a lot of complication and a lot of loss that accompanies that, but that it is not overwhelming, and that it is not too much. It may be very big, but, um, it is again, uh, it will be doable, and he will get through it if that does indeed happen.

What about the, uh, global negative rating? Well, instead of believing that the situation is absolutely hopeless, is to realize that, um, it's not going to, it will be good, but it won't negate all hope. Here, there will still be hope in, in life. The global negative rating of the self is that he is a failure as a father, is to realize that, well, you know, he makes mistakes as a father, and certainly he does make mistakes, but, um, it is not helpful in any way to generalize and say that he is nothing but, he does nothing but make mistakes. And even if he does make a mistake and experiences failures, making a mistake and in failing at things does not make one a complete failure. The same thing with weak. There may be instances in which he is experiencing weakness, but to say that he's nothing but weak is, is not helpful. Um, that, that there are times when he is weak.

Okay, so you see these would be more functional, uh, alternative beliefs to what he is thinking when he, um, is, uh, in the depths of the, of the depression. Now, let's shift to the client's goal. Remember, the client's goal, Juan stated that his goal in therapy is, [Music] he wants to be happy again. But let's think about it. This may not be the most workable or optimal kind of goal for Juan right now in the therapy. He's just gotten word that his wife wants a divorce. Even if she does divorce him, to expect happiness from him, um, is maybe too large of a leap. And so typically within REBT, when an individual is experiencing a dysfunctional negative emotion, when we're looking at the goal, typically what we try to negotiate with the client is moving first from the dysfunctional negative emotion currently experienced by the client, in this case, depression, and, and with there, moving to a functional negative emotion. So sadness. Sadness would be more reachable for him than happiness. And so, jumping all the way from depression to happiness doesn't, is not particularly reasonable, and it doesn't make a whole lot of sense that for an individual who believes that the divorce is not good, and that that not good, that he would be happy about that negative situation. So it doesn't seem very reasonable. A more reasonable goal here to try to negotiate with the client would be to experience some sadness, and then maybe later on, in, uh, in, uh, move toward embracing happiness in the, in other areas of his life. He may never be happy about the, about the divorce. So moving from depression to sadness would be a much more, um, reasonable, uh, goal in that particular case.

Okay, so this is going to be very, very common within REBT. So Juan may have said, instead of that he wants to be happy, that he just doesn't want to feel anything. Well, not feeling anything is not a viable option because one, it's a negative situation, and you feel nothing about a negative situation is probably not very helpful. But to having a helpful negative emotion about that negative event would be a much more adequate and reasonable, reasonable goal. We would normalize the desire, maybe not to feel anything, and certainly normalize wanting to be happy, but what we want to look at is the functionality and reasonableness of attaining that within, uh, therapy, at least initially, within, within therapy. So I hope that is a help, help there.

So let's move to what can we do with the information that we got in this particular case, and we've conceptualized it using the ABC and, uh, and what goes into the conceptualization of, in this case, depression? Well, um, there would probably be, we can do, start in a couple of different ways here. Once we've gotten the goal and negotiated with the client, one would be to deal with the cognitions, the dysfunctional cognitions for inferences and beliefs, and then all, once we've done that, or simultaneous with it, or even before we do the cognitive restructuring, address the action or behavioral potential, deal via behavioral interventions. And remember, the action or behavioral potential for Juan right now is withdrawal from his children and from friends, which is not really helpful, um, in the midst of a, in the midst of a depression.

But let's, um, begin with cognitive restructuring. Now, what we're doing with cognitive restructuring, whether we're looking at inference or beliefs, is first we have to identify what the inference, inferences are. We have to identify what the beliefs are. Then we want to go through a process of challenging them. And then once we've challenged them, and the goal of challenging them is to help the client see the dysfunctionality of those beliefs, that they don't help the individual attain their desired life goals. Once the client realizes the dysfunctionality of them through that process of challenging the beliefs, then is to change those, uh, change those beliefs.

So let's go through that, uh, beginning with the inference. Now, um, with his inference, you know, that was what that this was, um, you know, this, uh, would be the biggest loss that he has ever experienced. It would be huge, in fact. And so what we want to do with him is one, acknowledge that that is indeed his inference, and that that is certainly normal for him to have that inference. But then to shift to help him see, instead of it being an overwhelming loss, that in fact, we will discuss ways in which we can manage that loss. So instead of being an overwhelming loss, that there are parts of it at times may seem difficult to manage, but that he will be able to manage that loss. And then, in fact, um, particularly if the marriage was not good over a good amount of time, that in the midst of the loss, there may be opportunity for him to learn from whatever errors he made within that marriage, in case he ever wants to get into another significant relationship like that. So move from seeing this as nothing but a loss to, yes, a loss, a manageable loss, but perhaps with some opportunity or opportunities that will come up within the remainder of his life.

And then if we move to the disputation of the beliefs, remember, and I'm not going to go through all of those beliefs again, but what we will go through a systematic process of challenging, challenging each of those beliefs, and we will challenge them sequentially. Once we finish challenging and replacing one of the dysfunctional beliefs, then we switch over to challenging and replacing the next dysfunctional beliefs until we have done that with all of the dysfunctional beliefs associated and, uh, causing the dysfunctional negative emotion in this case of Juan's depression.

Now, remember, and, uh, for my students who may be watching this right now, that they will, um, there are four or five different ways in which we systematically challenge. And let me just name those, describe them, and then take one of, one of Juan's dysfunctional, [Music] beliefs and then systematically challenge that. My students, we will be looking at that in the upcoming weeks. And so the typical and traditional kinds of challenges to dysfunctional beliefs that we have within REBT are what we call a pragmatic or functional dispute. That is, we ask the client about the dysfunctional belief, "How is holding this dysfunctional belief helping you? What do you get out of holding this dysfunctional, dysfunctional belief?" And then another one would be an empirical dispute. That is, "Where is the evidence that supports that? Where is it written, uh, the truth of the truthfulness of that belief?" And then once we, uh, challenge that, then that one, then we would challenge it logically. Uh, and there we go. I understand that you don't want to get this to happen, but how does it logically follow that because you don't want it to happen, then it must not happen? Okay. And then the friendship dispute is, let's say you have a friend that's going through the very same situation that you are, and they're holding that dysfunctional belief. What would you say to them? Would you say, "Absolutely, you're absolutely right," and then, you know, solidify them there in their dysfunctional negative emotion, or would you, would you reject them and say, "Ah, you're utterly illogical. I can't be around somebody like you." What would you do? What would you do?

And so, um, so those are four different ways of, uh, of challenging. And so let's take one of Juan's dysfunctional beliefs and challenge it using each of those techniques. And remember, Juan said that he was a, a failure as a father. So let's challenge that belief that he's a failure as a father in each of these ways. So he might, as a therapist or a counselor, say, um, "How is it helping you to say that you were nothing but a failure as a father?" And, uh, what our goal is, is to help him realize that putting that upon himself is not going to help him in any way. If he really believes that he's not, uh, anything but a failure, then he just gives up and is not going to hang in there and strive toward becoming the father that he wants to be. So that's the pragmatic dispute.

The empirical one is, "Where's the evidence that you are nothing but a failure?" Right? Um, and so if it goes well, you know, sometimes say inappropriate things, then we would say, "Well, that's evidence that at times you say something inappropriate. How does it follow then that you're nothing but a failure?" Right? We all have, make mistakes, but how does making a mistake mean that you are a complete and utter failure, which means you fail at everything, that means you would fail at everything as being a father? So what we want him to realize is there is no overwhelming empirical evidence that he is nothing but a failure.

The logical one, when we might go, "Well, I understand that you don't want to make mistakes as a father. That how does it logically follow then because you made mistakes that you're nothing but a failure as the father?" Doesn't logically follow.

And the other one is, "Let's say you had a friend who is going to do the very same thing that you are going through, a, you know, a divorce, and, um, and believes that they are a failure as a father. Would you go, 'Well, absolutely, I've been meaning to tell you, I think you're nothing but a failure as a father,' and they go, 'No, no, of course I'm not going to say that to them.' And we go, 'Why wouldn't you?' 'Well, because that doesn't help.' Well, um, that wouldn't be uplifting, that wouldn't be encouraging.' So yet then we're like, 'Well, then it probably won't be uplifting and encouraging to you.' So what could we put, what belief could we put in its place?"

So you see, we're going to pragmatically, empirically, logically, and then through a friendship dispute, um, challenge these beliefs, and then so that we can help him to go, get him to embrace a more helpful belief is that, "Yeah, I make mistakes, and I make mistakes as a father, but that doesn't make me a nothing but a failure as a, as a father."

Okay, so I hope this was, uh, helpful. And in the next, uh, lecture that we have, where you can ask about your questions, etc., then, um, we will, um, we will, um, you know, we will look at that and, uh, discuss any questions that you have at that time. So think of questions that you would like to ask over this, and in class on the next lecture that I give for Gift University, then you can just post those questions. Thank you so much, and have a.