Problem
Case Study Ted
Ellis often applied disputational strategies along with other cognitive, behavioral,and emotive approaches to individuals with anxiety disorders that may includepanic or physical symptoms. He believed that significant improvement can beobtained in a few weeks and that therapy can be completed in 10-20 sessions(Ellis, 1992a).How Ellis used REBT for anxiety disorder can be illustrated by the case of Ted,a 38-year-old African American man who has been married for 10 years and hastwo young children. Referred by his physician because of pseudo-heart attacks(which really were panic attacks), Ted has complained of chest pains, particularly when riding a train between Jersey City and Manhattan. Ellis's approach wasto obtain a brief family history and to administer several tests, including theMillon Clinical Multiaxial Inventory II. Ted's only high score on this instrumentwas on the anxiety scale. In the first session, after determining Ted's symptomsand obtaining family background, Ellis deals with Ted's "shoulds, oughts, andmusts." In the following brief segment from the first session, Ellis challengesTed's "musts" and explains his irrational beliefs:
Therapist: Well, if we can help you to change your ideas and attitudes abouttaking trains and about having a heart attack, that will really help you andyou won't need medication. You see, you said you were a perfectionist. Soyou're first making yourself anxious about doing things perfectly well. "Imust do well! I must do well!" Instead of telling yourself, "I'd like to do well,but if I don't, F ... it! It's not the end of the world." You see, you're rarelysaying that. You're saying, "I've got to! I've got to!" And that will makeyou anxious-about your work, about sex, about having a heart attack, orabout almost anything else. Then, once you make yourself anxious, youoften tell yourself, "I must not be anxious! I must not be anxious!" That willmake you more anxious-anxious about your anxiety. Now, if I can helpyou to accept yourself with your anxiety, first, and stop horrifying yourselfabout it; if we can help you, second, to give up your perfectionism-yourdemandingness-then you would not keep making yourself anxious. Butyou're in the habit of demanding that things have to go well and that, whenthey don't, you must not be anxious about them. "I must not be anxious! Imust be sensible and sane!" That's exactly how people make themselvesanxious-with rigid, forceful shoulds, oughts, and musts.
Client: Like yesterday. Yesterday was my worst day in a long time.
Therapist: Yes, because?
Client: What I did is when I was going to the train, I said: "I need to putsomething in my mind."
Therapist: To distract yourself from your anxiety that you expected to havewhen you got on the train?
Client: Yes. I said, "I am going to buy some sports things for the children." SoI went to one of the stores and I bought some things, and as soon as I goton the train I started deliberately reading. Ten minutes after I was on thetrain, I still didn't have any anxiety. I was okay. But then I rememberedand I said, "Jesus, I feel okay." At that moment, I started feeling panickedagain.
Therapist: That's right. What you probably said to yourself was, "Jesus, I feelokay. But maybe I'll have another attack! Maybe I'll get an attack!" Youwill if you think that way! For you're really thinking, again, "I must notget another attack! What an idiot I am if I get another attack!" Right?
Client: Yes. (Ellis, 1992a, pp. 39-40)
Later in the first session, Ellis continues to dispute Ted's irrational beliefs ofhaving an attack on the train. He also suggests self-statements that will be usefulwhen riding the train.
Therapist: So suppose you do have an attack on the train? What's going tohappen to you then?
Client: Something will happen to me.Therapist: What?
Client: Most of the time I've said to myself, "Okay, nothing will happen.Because I know that whatever I have is not a heart problem-it's amental problem, and I create it myself." So I then relax. But what'sgetting to me is that I have to deal with the same thing every day. Everyday I have to deal with it.
Therapist: I know. Because you're saying, "I must not be anxious! I must notbe anxious!" Instead of, "I don't like being anxious, but if I am, I am!"You see, you're terrified of your own anxiety.
Client: That's exactly what it is!Therapist: Okay. But anxiety is only a pain in the ass. That's all it is. It doesn'tkill you. It's only a pain. Everybody gets anxious, including you. Andthey live with it!
Client: It's a big pain in the ass!
Therapist: I know. But that's all it is. Just like-well, suppose you lost allthe money you had with you. That would be a real pain, but youwouldn't worry about it too much, because you know you'd get somemore money. But you're making yourself terrified. "Something awfulwill happen. Suppose people see I'm so anxious! How terrible!" Well,suppose they do.
Client: I don't care about that.
Therapist: Well, that's good. Most people are afraid of that and it's good thatyou're not.
Client: When I walk to the train, I know that I am going to start feelinganxious.
Therapist: You know it because you're afraid of it happening. If you said toyourself strongly and really believed, "F ... it! If it happens, it happens!"Then it won't even happen. Every time you say, "I must not be anxious! Imust not be anxious!"-then you'll be anxious. (Ellis, 1992a, p. 45)
In the remainder of the first session and in the second session, Ellis continuedto go over and over the essentials of REBT, pointing out ways in which the clientupset himself. He gets quickly to the central problem for Ted and helps him dosomething about attacks on the train. The following comments are taken from thethird therapy session and indicate that Ted has been working hard and success-fully to apply the principles of REBT:"I'm feeling better. Whatever I'm feeling, like anxiety, is not it. I'm creating it. What-ever I'm feeling I can make it go away in a couple of minutes and if I get upset aboutmy anxiety, I can talk to myself about that."When I get to the train I'm not that anxious.... Like this morning, I completelyforgot about it until I was on the train. Then I remembered and started saying to my-self, 'It's nice to be feeling the way I'm feeling now.' It doesn't bother me anymore....And last week, a couple of days, I'm going home, I fall asleep on the train, and I wakeup at my station and I said to myself, 'Whatever happened a couple of months agois gone.'"And even in my work I don't feel anxious. I am working better than beforewithout getting that, uh, anxiety to make everything fast and quick. I can pace myself better than before.... Another thing I learned to do: not to upset myselfabout the others in my office who act badly. If I got upset, they're going to act thesame way."Before I thought my anxiety meant something was physically wrong.
Now I seethat I'm creating that sick feeling. Two or three minutes later, I am okay. Two weeksago it would have taken me fifteen minutes to be less anxious. Now it takes me two orthree minutes and there are days when I don't feel panic."The other day I got to the train when it was almost full, and I couldn't sit downand read and distract myself. But it didn't bother me and I didn't wait for anothertrain as I used to have to do.... I can talk to myself and say, 'Look, whatever anxietyyou feel, you created it. And you can uncreate it.'" (Ellis, 1992a, p. 51)This was Ted's third and last individual session with Ellis. After this, heattended Friday Night Workshops at the Albert Ellis Institute. He also partici-pated in several four-hour workshops. Both Ted and his wife reported that he hasmaintained the gains that he made, has lost his panic about trains, and was rarelyanxious or angry at the office.
Task
A. Identify the A-B-C of the case.
B. Describe how the therapist in the case study is using D.
C. Identify the E that the client and therapist are looking for in the case study.