Effectiveness of Outpatient Rational Emotive Behavior Therapy Over One Decade

Cognitive-behavioral therapy (CBT) refers to several forms of psychological treatments that share the same core principles: the cognitive evaluation of internal or external events represents the basis of emotional reactions and behaviors, cognitive constructs and their emotional and behavioral effects can be identified through monitoring, and cognitive and behavioral techniques (or other psychological techniques) can be used to change maladaptive cognitions to bring about changes in emotional distress and problematic behaviors (1, 2).

Fundamentals of CBT

Rational emotive behavior therapy (3, 4), currently called rational emotive and cognitive-behavioral therapy (REBT), uses the original foundational approach of CBT. REBT is organized around the concept of rational and irrational beliefs (3, 4) and, in keeping with the CBT framework described above (1, 2), states that one’s emotional and/or behavioral reactions to certain activating life and/or personal events are largely mediated by the beliefs that one holds about these events. According to Ellis (4), there are two types of beliefs—irrational and rational—and four irrational or rational categories: demandingness versus flexible and motivational preferences, awfulizing or catastrophizing versus nuanced evaluation of badness, frustration intolerance versus frustration tolerance, and global evaluation (of self, human worth, others, and life) versus unconditional acceptance (of self, others, and life) (1, 5). Demandingness represents a primary irrational process, but not one that is proximal to emotional reactions. Indeed, demandingness leads to the secondary irrational beliefs (i.e., awfulizing and catastrophizing, frustration intolerance, and global evaluation), which are more proximal causes of dysfunctional emotions and psychopathology (1).

REBT theory distinguishes between functional and dysfunctional emotions on the basis of the association made by individuals between events and cognitions and whether the behavioral consequences of these feelings are adaptive (4). Negative emotions that follow irrational beliefs about negative events are called dysfunctional negative emotions, whereas emotions that follow rational beliefs about negative events are called functional negative emotions (2).

Both REBT and CBT assume that individuals can change their unhealthy beliefs to healthy ones, which implies that individuals have the choice of showing functional or dysfunctional feelings and behaviors (6). In more recent work, the REBT approach, compared with most other CBT methods, has been described as using different ways to help clients reach three major acceptances: unconditional acceptance of self, others, and life (6). In studies of the two approaches, CBT has been tested more with specific-disorder protocols, whereas REBT has been used more with a transdiagnostic approach.

From Efficacy to Effectiveness Studies

Randomized controlled trials (RCTs) are the gold standard in testing the efficacy of any psychological treatment (i.e., the treatment works in controlled conditions and maximizes internal validity). To date, CBT (REBT alone or considered as a part of CBT) has been among the psychological interventions empirically investigated most frequently and has received the most empirical support (7, 8). The efficacy of CBT has been evaluated in several meta-analyses (9–13), with positive results. More recently, the evidence supporting CBT has been strengthened by several rigorous clinical trials (14, 15) and meta-analyses (16–18).

However, questions remain concerning the procedures used for increasing internal validity in RCTs—procedures that may compromise the external validity of the results. Specifically, these questions pertain to generalizability across patients, clinicians, and treatments used and about whether these characteristics of clinical trials are representative of clinical practice. Moreover, some studies (19, 20) have found that up to 70% of patients who could benefit from depression treatment would not have been eligible to participate in a RCT efficacy study. The most common reasons for excluding patients from RCTs have been that they received subclinical diagnoses, had comorbid psychiatric diagnoses, or received adjunct treatments, such as medication. Because of these exclusionary problems and because efficacy studies fail to provide information about the transportability of interventions to more ecologically valid conditions, psychotherapy research requires an emphasis on effectiveness trials that evaluate interventions implemented under naturalistic conditions (21, 22).

Effectiveness research investigates whether interventions that were tested in RCTs attain similar benefits in naturalistic settings; such research can include pretest-posttest, quasi-experimental, or experimental designs. According to Stewart and Chambless (23), a study design can be categorized as having external validity when it achieves at least one of the following characteristics: it captures data in clinically representative settings (e.g., outpatient clinics, mental health centers), uses clinically representative therapists (e.g., practicing clinicians who do this job daily), or studies clinically representative patients (e.g., has few exclusion criteria). Additionally, the transdiagnostic approach to the treatment of clinical problems reflects the current at-hand orientation in real practice, as opposed to the model of selected interventions for specific disorders that characterizes randomized trials.

Several reviews have synthesized the results of CBT effectiveness studies. Stewart and Chambless (23) conducted a meta-analysis of 56 CBT effectiveness studies for adult anxiety disorders to investigate whether CBT tested under well-controlled conditions can be generalized to less controlled settings. The effect sizes from pretest to posttest for disorder-specific symptom measures were large, suggesting that CBT for adult anxiety disorders is effective in clinically representative conditions. The findings demonstrated that results from effectiveness studies are similar to those obtained in efficacy trials. Hans and Hiller (24) conducted a meta-analysis of 34 CBT effectiveness studies of outpatients receiving individual and group therapy for unipolar depressive disorder. Results showed large posttreatment effect sizes for reducing depression severity with outpatient CBT and moderate-to-large effect sizes for secondary outcomes. In a study of general psychological distress, Twomey et al. (25) demonstrated the effectiveness of a computerized CBT program (MoodGYM, d=0.48) in reducing psychological distress among a sample of 149 public mental health service users. Hickie et al. (26) found effect sizes in the same range (d=0.4) when measuring the level of psychological distress from pre- to posttest. Although the results were consistent with previous findings showing that individual and group outpatient CBT can be effectively transported to clinical practice, the study also found that patients encountered in clinical practice showed less improvement in depressive symptoms than did participants in RCTs.

A commonly used method in ecological studies of psychotherapy, especially with center-based samples, is to track symptom change during therapy. The Outcome Questionnaire–45 (OQ-45) (27) has become one of the 10 instruments most frequently used by practitioners to measure clinical outcomes (28). Research using this type of measure has helped researchers identify whether patients receiving high doses of therapy would be no more likely to experience a clinically significant change than those who receive low doses (29–30). Baldwin et al. (31) evaluated the dose-effect relationship and model of change by examining the relationship between the rate of change and total dosage of sessions among 4,676 patients who received individual psychotherapy. They showed that 1,242 patients achieved clinically significant change (measured with the OQ-45) and that faster rates of change were registered by the patients receiving small doses of treatment, whereas slower rates of change were linked to receiving larger doses of treatment.

Other important variables that can be investigated in such naturalistic studies of psychotherapy effectiveness are dropout rates and course of patients’ treatment response. High dropout rates (24%–66%) have been reported by studies (32, 33) conducted in mental health centers. Low motivation for change was identified as a primary reason for dropout (34). Studies addressing the long-term outcomes of psychotherapy found that early responders (e.g., patients improving within the first three sessions) had better outcomes at therapy termination and maintained their therapy gains (35). Moreover, an early positive response to psychotherapy has been found (36) to be a powerful predictor of outcomes among various samples. Also, some studies (37–39) have documented the effectiveness of brief time-limited therapy (eight to 16 sessions or five sessions of CBT) (30, 37). It has been suggested that about 50% of treated patients in routine care might recover if they received about 18 to 21 sessions of psychotherapy (40), although about 50% of clients will show reliable improvement after only seven sessions. However, it is also known that deterioration rates for patients in routine practice settings can be as high as 14% (41), whereas the response rate (recovered and improved patients) for patients with clinical symptoms participating in 20 sessions of therapy is around 40% (31).

Study Overview

To our knowledge, systematic studies to date have not yet investigated the effectiveness of REBT. This research gap is surprising, because REBT has been practiced as the original form of CBT, and, from the beginning, the REBT literature has more closely resembled an effectiveness framework than an efficacy framework. Indeed, the Albert Ellis Institute (AEI) has for many decades offered services to the community that are based on the REBT model, focus on clinical problems as they appear in real life, are provided by therapists whose main job is conducting therapy, and implement both the transdiagnostic and categorical diagnostic approaches. Thus, the AEI seemed to be the perfect setting to evaluate the effectiveness of REBT with the purpose of understanding the impact of CBT more generally. Therefore, in this study, our main hypothesis was that the use of REBT can improve psychological functioning, expressed as lower symptom severity, of a sample of outpatients in naturalistic conditions.

Methods

Participants

Data from several hundred adult patients of the AEI who sought REBT from 2007 to 2016 were culled from AIE records for this study (child patients will be analyzed in a future study). The yearly distribution of patients included in the study, by year of intake, is presented in Figure 1.

We limited our analyses to patients who received at least one therapy session; we considered 20 sessions of therapy as posttest (a prototype number for the CBT sessions). Thus, we included 349 patients who had participated in at least one session of therapy after intake and had provided the data necessary for our analyses. Of the participants, 55% (N=192) were women, and 44% (N=154) were men (<1% [N=3] missing data); ages ranged from 18 to 75 years (mean±SD=35.39±11.44). Of the participants, 83% (N=290) completed at least three sessions of therapy, and 17% (N=59) completed all 20 sessions. The mean intake OQ-45 score among participants was 74.05±23.39, which has been previously considered typical for outpatient therapy settings (27).

Therapists’ Training

Therapists who participated in the study were either staff therapists at the AEI or trainees. All staff therapists had received at least 2 years of training at the AEI. The trainees were psychology doctoral students completing an externship, internship, or postdoctoral training. All therapists completed 3 days of primary training and 4 days of advanced training in REBT before they began treating study patients. Training required the therapists to read seminal books in REBT; attend eight lectures on REBT theory, techniques, and applications to clinical problems; and complete eight peer-counseling sessions that were observed by a supervisor who provided in vivo feedback. The therapists received weekly supervision, which included reviewing recorded sessions and receiving feedback on their therapy sessions, from an experienced licensed psychologist as well as an REBT- and CBT-certified supervisor. The licensed staff therapists attended clinical case conference meetings once a month to discuss their cases, and unlicensed staff had weekly supervision by a licensed psychologist and a certified REBT and CBT supervisor.

Outcome Assessment

We used the OQ-45 (27) to measure patient functioning. The OQ-45 is a widely used instrument for examining the effectiveness of psychotherapy over time, and it is considered useful for tracking changes in patients’ symptoms on a session-by-session basis (42). The OQ-45 consists of 45 items each scored on a 5-point Likert-type scale. The instrument can be scored as a total across three subscales assessing symptom distress, social role functioning, and interpersonal relationships. The symptom distress subscale measures general emotional and behavioral symptoms, such as depression, anxiety, stress, substance abuse, and suicidality; scores range from 0 to 88, with higher scores indicating higher levels of distress. The social role functioning subscale measures patients’ work relations and leisure activities; scores range from 0 to 36, with higher scores indicating higher dissatisfaction in social roles. The interpersonal relationships subscale measures patients’ satisfaction with interpersonal relationships, such as marital and family relationships and friendships; scores range from 0 to 44, with higher scores indicating greater problems in interpersonal relationships. The total OQ-45 score, ranging from 0 to 180, has been found to be reliable and valid (43) and distinguishes between individuals with clinical and nonclinical symptoms.

Patient Enrollment and Involvement

Patients were enrolled between 2007 and 2016 at the AEI in New York City. The only inclusion criterion was being older than age 18. We based this decision on the fact that the transdiagnostic approach is dominant in real clinical practice as opposed to in randomized trials (44). Patients were assigned to a therapist on the basis of the availability of time slots that matched the patients’ and therapists’ schedules. The study was approved by the institutional review board of the AEI.

Patients received an intake packet of questionnaires prior to their first session, which they began completing before their session and finished after that session or a subsequent session. The questionnaires included the Millon Clinical Multiaxial Inventory–III (45), the Psychiatric Diagnostic Screening Questionnaire (46), the Attitudes and Beliefs Scale–2 (47) (a measure of irrational and rational beliefs), and a four-page case history background questionnaire created by AEI staff (48). The therapists used this information to develop a case conceptualization for each patient. Patients completed the OQ-45 before entering therapy and then before each session to monitor their progress.

Treatment Selection and Key Decision Points

All patients received REBT at the AEI. Each session lasted 50 minutes, opened with a “mood check,” and continued with a review of the previous session and homework follow-up. The therapist and patient set the agenda and approached it based on the transdiagnostic ABC(DE) model (4, 48, 49). Patients learned the ABC(DE)s of their emotional disturbance, which consisted of identifying their activating events (A), their beliefs (B) about the activating events, and the resulting emotional and behavioral consequences (C). They learned to identify their irrational beliefs and to recognize the connection between the irrational beliefs and the emotional and behavioral disturbance, thus learning that the irrational beliefs could be replaced with rational beliefs to experience functional emotions and adaptive behaviors. Ellis’ elegant solution (48) was used in approaching patients’ beliefs, as the therapists focused on changing patients’ surface (e.g., it is awful that she does not love me) and core irrational beliefs (e.g., it is awful to not be loved by loved ones) and not automatic thoughts in the form of descriptive (e.g., my wife has another partner) or inferential cognitions (e.g., she does not love me). Patients’ irrational cognitions were approached by using empirical, pragmatic, and/or logical cognitive restructuring and/or debating strategies (D) that were based mainly on Socratic questioning in the context of a sound therapeutic relationship. Humor, metaphors, and spirituality- or religion-informed techniques were also used for cognitive restructuring when appropriate. Effective life philosophies (E), reflecting rational thinking, were elaborated on to replace the irrational beliefs. At the end of each session, homework assignments were negotiated in connection with the therapeutic goals, such as monitoring one’s mood by using the ABC(DE) self-help form, debating one’s irrational beliefs, rehearsing rational beliefs, and conducting behavioral experiments in the form of shame attacks. Behavioral strategies were used to target irrational beliefs, strengthen conviction in the rational beliefs, and/or target unconscious information processing (e.g., exposure to counter maladaptive classical conditioning). Problem-solving strategies were used to deal with the activating events, after the dysfunctional feelings and/or behaviors were changed to functional feelings and/or behaviors or during some crisis situations. Coping skills were also used to deal directly with consequences, especially in the crisis situations and for various homework assignments.

Statistical Procedures and Analyses

An alpha level of 0.05 was used for all statistical tests. Participants were included if they had completed at least one therapy session; participants who had participated in fewer than three sessions were considered to have dropped out of the study (38). Analyses concerning the outcome were conducted by using the intent-to-treat principle: the pairwise-comparison analysis included all patients, regardless of their protocol adherence or subsequent withdrawal from the study or assessments. The last available score on each outcome measure served as the termination score for those who dropped out of the study. We included analyses for early responders after three sessions of therapy (i.e., the early-response phase) and at the end of the 20 sessions (i.e., therapy termination). This decision was based on the literature (35) documenting the dose-effect relationship, which has shown that a positive early response to treatment can occur within the first three sessions, and research (40) supporting a good-enough level model of change. Effect size analyses for outcomes were based on Cohen’s d coefficients (50). We used Morris and DeShon’s (51) equation 8 to correct for dependence between means for within-subject data.

Treatment responses were also analyzed categorically, by using cutoff scores indicating symptoms of clinical significance and reliable change norms of the outcome (27). Reliable change is indicated when a patient’s score changes by 14 points or more on the OQ-45 total score. The following categories and criteria were used: “recovered” (patients with clinical scores at intake that improved and moved into the nonclinical range at termination, as indicated by the reliable change index), “improved clinical” (patients with clinical scores at intake that improved [reached a reliable change level at termination] but remained in the clinical range), “improved nonclinical” (patients whose scores were initially in the nonclinical range and registered reliable improvement at termination, with the score remaining in the nonclinical range), “deteriorated clinical” (patients with scores in the clinical range at intake that deteriorated with a reliable change level at termination), “deteriorated nonclinical” (patients whose scores were in the nonclinical range at intake but deteriorated with a reliable change level at termination), and “no reliable change” (patients whose scores did not register a reliable change level at termination). We used the same categories to analyze the recovery rates and clinically significant changes after the early-response phase (after three sessions) and at the termination phase (20th session).

Results

Descriptive Analyses

Table 1 presents the means and standard deviations for the participants’ total scores on the OQ-45 and its subscales. At intake, 75% (N=262) of the participants registered a total OQ-45 score above the clinical cutoff score, with 70% (N=244) of the patients scoring in the clinical range for symptom distress, 69% (N=241) for social role functioning, and 74% (N=258) for interpersonal relationships.

Treatment Attrition

Treatment dropout (i.e., completing fewer than three therapy sessions) was 18% (N=63). Of the participants, 73% (N=262) completed more than three sessions (24% [N=84] completed only three sessions), and 25% (N=87) completed 20 sessions. Patients attended a mean of 4.35±6.21 sessions, and 23% (N=80) attended more than 20 sessions (up to 112 sessions, with 9% [N=31] attending more than 40 sessions).

Inferential and Continuous Analyses

Descriptive statistics and comparisons between the total OQ-45 score at intake and the scores reported for each session are presented in Figure 2 and Table 2. We found significantly lower symptom severity for patients at the early-response phase (after three sessions), at termination (20 sessions), and at the last session, compared with the intake assessments for both the OQ-45 total scores and the OQ-45 subscales (all p<0.001) (Table 1).

Categorical Analyses

Thirty-seven percent (N=129) of the patients had nonclinical total OQ-45 scores after the early-response phase, 46% (N=161) had nonclinical scores at termination, and 47% (N=164) had nonclinical scores after their last session of therapy. Of the patients, 34% (N=119) registered reliable change improvements after the early-response phase, 49% registered reliable change at termination (N=171), and 50% at their last session (N=174). Table 3 presents the recovery status of the participants after the early-response phase and at termination. Significant changes were found in clinical status of the patients’ total OQ-45 scores at intake compared with after the early-response phase (χ²=69.18, df=1,349, p<0.001, ε²=0.44) and at the termination of therapy (χ²=94.35, df=1,349, p<0.001, ε²=0.52).

We conducted exploratory correlation analyses between symptom severity and the number of therapy sessions attended. Significant correlation was found between the number of sessions and symptom severity at the end of treatment (r=–0.582, df=349, p<0.001; values were similar for clinical [r=–0.588, df=262, p<0.001] and nonclinical [r=–0.577, df=87, p<0.001] participants).

Discussion

In this study, we aimed to document the effectiveness of REBT provided at the AEI over a decade in improving the psychological functioning of adult patients. At intake, participants had percentages of clinical-level OQ-45 scores that were similar to those of other studies of community samples (38). More than three-quarters of the participants attended at least three therapy sessions, one-quarter participated in 20 sessions, and more than 22% attended all sessions prescribed for them. In addition, the dropout rate seemed to be in range with other studies (24), which have reported rates between 8.05% and 42% in individual outpatient CBT treatment groups.

Our main finding was that patients reported significant improvements in functioning after participating in the REBT intervention, with medium effect sizes seen at both the early-response phase (after three sessions), at the termination of 20 sessions of psychotherapy, and at the last session of therapy. Moreover, session-by-session comparisons showed that significant improvements in patient functioning were evident, starting with the very first session of REBT, reaching a medium effect size at the third session. The highest effect size was reached at the eight-session threshold and again at the eighteenth session.

We also documented significant reductions in the proportion of patients with clinical symptoms at termination. Although 75% of the sample at intake had a clinical level of symptoms, as documented by the OQ-45, half of the patients moved into the nonclinical range of functioning by the termination of therapy. Significant differences were found between the proportion of patients scoring in the clinical range at intake and at termination of therapy, with 23% (N=80) of the participants initially having clinical-level scores no longer qualifying for this range of impairment at the termination of therapy. These results (e.g., 49% reliable improvement in REBT) were slightly higher than those reported in the literature (31) (response rates of 20%–40%), and patients receiving REBT seemed to display lower deterioration rates (6.8% in REBT versus as high as 14% reported in the literature) (41). Moreover, our exploratory analyses suggested that the number of sessions attended correlated significantly and negatively with symptom severity at the treatment end.

Compared with results of other effectiveness studies, the REBT conducted at the AEI seemed similar to rates of clinical response in other clinical settings (31) but showed lower levels of deterioration (41). On the other hand, similar to all other effectiveness studies regarding CBT, the clinical effect of REBT in real life seems to be lower (mostly having medium effect sizes) than its clinical effect in controlled conditions (9). However, this result may be due to the complexity of the clinical cases that occur when the exclusionary criteria of RCTs are removed. Additionally, this result may be caused by a somewhat lower adherence to evidence-based protocols in practice, compared with at research centers. To counter this latter potential cause, during the transport of a clinical protocol from controlled conditions to real clinical practice, the protocol needs to be kept as unchanged as possible.

This study had several limitations. An important limit of this study was the missing information regarding patients’ diagnoses or previous therapy experiences. A second limitation was the lack of measures for documenting mechanisms of change. Both specific and common factors need to be measured and considered in future studies in order to investigate the relevant mechanisms of change.

Conclusions

To our knowledge, this was the first study to investigate the effectiveness of REBT delivered over 10 years in a world-class outpatient center such as the AEI in New York City. Although controlled studies have shown that REBT is effective, it is essential to document whether REBT has similar effectiveness, compared with other forms of CBT, in naturalistic settings. Our findings document that REBT can be effectively transported to clinical practice settings, supporting the use of REBT for a wide range of life problems in real clinical settings. Thus, this study brings important contributions to the literature in terms of the efficacy of REBT implemented in naturalistic conditions, in the very institute where it was developed. More high-quality effectiveness studies are needed to further document REBT’s outcomes, mechanisms of change, and cost-effectiveness or cost-utility and to study the characteristics of treatment provision that may contribute to the reduction of dropout rates and an increase in effect size. Indeed, cost-effectiveness and cost-utility analysis of REBT in clinical settings are the next items to investigate, because REBT has proven its cost-effectiveness and cost-utility in efficacy studies.