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Using a religion augmented REBT intervention for an anxiety case in a theology student

Autor: Viorel Lupu Laura Nussbaum Andra Isac Izabela Ramona Lupu
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This paper presents the case of a 21-year-old theologist suff ering from marked anxiety, which was treated, initially, with medication (Fluoxetine and Alprazolam) and a technique to control breathing – breathing in three steps, and afterwards by applying rational emotive behavior therapy (REBT) techniques augmented with religious elements. Adequate examples, especially in disputing irrational cognitions, were essential for the success of the therapy. Passages from the Bible and examples from Jesus Christ’s life were used. In the same time, we bring arguments for a correct evaluation before initializing REBT with religious elements by the therapist, who needs to know the content and the defi ning lines of diff erent religious cults, in order to decrease the risk of a therapeutic failure. By adapting the intervention in this way, we favour the therapeutic relationship, which is essential for a successful therapy. Key words: rational emotive behaviour therapy, religion, anxiety

In any type of psychotherapy, the therapeutic relationship plays a fundamental role, contributing, according to some authors, in a proportion of 30% to the success of the intervention [1]. This is why in psychotherapy we look for elements to positively influence this relationship and, implicitly, the results of the therapy. One of the most important factors that influence the therapeutic relationship is empathy, which is the capacity to walk in the shoes of our clients, to understand their thoughts and emotions/ feelings, without judging them [2]. This can be done by using a language that is within reach for the client and that facilitates a positive transfer. Rational emotive behavior therapy (REBT) is a consecrated form of psychotherapy, being developed by Albert Ellis (1999) and is based on the idea that emotions and behaviors appear as a result of cognitive processes [3], more specific, as the interpretation that each person gives to events surrounding him/her and not as a result of those events.
These principles are based on the theory that it is possible for people to change the emotions and behaviours they experiment by modifying their thoughts and ideas. Ellis set up the famous ABC model which aims to replace the inappropriate, inflexible attitudes, like worthlessness (“I am a worthless person if I do not excel and if I do not win the approval of others”), exaggeration (“It is terrible and awful if I do not do everything how it is supposed to be”), and intolerance (“I cannot stand the things that happen to me and are not supposed to”) with flexible, adaptive attitudes. The examples given during the course of REBT need to be relevant for the client and match his/her reference system. So, the principle of a personalized intervention applies, which implies a lot of creativity and imagination from the therapist. In this context we describe a religion-augmented REBT intervention in the case of a theologist. Using examples and quotes from the Bible can only be beneficial in assuring the success of the REBT intervention.
To be efficient, before the intervention we need to do a complex evaluation of the client – concerning the diagnosis and the problems to be solved, that will turn into therapeutic objectives, and concerning aspects related to his potential religious beliefs. This is extremely important in order to avoid certain situations with which we could be confronted, like in the next example: <> Initially, A. Ellis (1960) considered, based on atheist philosophy, that religion is irrational, and it can disturb emotional life, saying about sin that it is one of the causes of psychopathological disorders [5]. He considered that religious beliefs that are dogmatically formulated lead to a precarious emotional health and contribute directly to mental disorders. Subsequently, the same author accepts that there is congruence between the rational-emotive philosophy and the divine grace philosophy from Christianity. He underlines the idea that religious or not religious beliefs don’t determine people to have healthy or unhealthy emotions, but the quality of those thoughts can perturb a person’s life, considering the fact that the atheist, Christian or Islamic way of thinking can have inflexible and absolutist ideas [6,7]. Robb (2001, 2002) showed that REBT can function well in any religion (Jewish, Christian, Muslim, Hindu, Buddhist, Taoist or other) that accepts the importance of modifying inappropriate thoughts, showing that the greatest obstacle in a person’s transformation is an absolutist religious way of thinking [8]. For example, the thought according to which “I have to pray three times a day for God to forgive me, otherwise I cannot forgive myself” will maintain the emotional discomfort, putting God in an unfavourable light and loading the individual with tasks that do not bring a freeing from guilt.
The healthy attitude would be: “because I want God to forgive me, I will ask for forgiveness through prayer, being willing to accept this forgiveness, because I know God loves me as a sinner, even though He does not love sin”. The results obtained by Koening, McCullough and Larson (2001) in their meta-analysis of 1200 studies and 400 researches in the area of physical health connected with patients’ religiousness, show that patients with an active religious life heal faster than non-religious patients, also having a lower death rate [9]. Starting from the premise that evaluative cognitions, also called hot cognitions, generate affective reactions – irrational cognitions lead to dysfunctional emotions, and rational cognitions to functional emotions, Balla (2013) studied the question: to what extent do irrational cognitions appear in religious thought [1,10]? He identified irrational religious cognitions like: absolute requirements towards God and others, catastrophizing and intolerance to situations of suffering, as well as globally evaluating oneself as a good or bad person. Also, he highlighted the connections between these irrational religious cognitions and dysfunctional negative emotions. The implication religion has over mental health is a controversial area and less studied, being associated with several aspects of adaptive functioning: it offers life meaning, contributes to an increase in the quality of life, maintains hope and optimism, contributes to a better management of dysfunctional behaviors (addiction, substance use), facilitates coping with difficult life situations, facilitates social support, offers a purpose to the perishable nature of the human being, offering a purpose in regards to life and death [11]. Roman (2013) studied therapeutic interventions for improving the distress of mothers admitted to a ward specialized in treatment recovery for children with neurological problems, who were divided into three groups – one control group, one group with standard REBT and one group with REBT and scriptural elements. “Psychological pills” were used in therapy, rational psychological statements designed to facilitate cognitive restructuring; each REBT method (classic or with religious elements) having had specific psychological pills. A rational prayer was learned by the religious REBT group, based on the ABCDE model, favouring cognitive restructuring. The results indicated significant differences between groups for all the measured variables (depression level, anxiety as a trait and as a state, anger) in post testing, in the mothers’ groups that had an intervention compared with the control group, indicating that the therapy had a beneficial effect. CASE STUDY Antony is a 21-year-old, second year Philosophy student and a novice in the monk order of the Jesuits. He presented for marked anxiety when in the Jesuit community, with somatic implications: palpitations, “thirst for air”, floating sensation, uncertainty and fear of exams. He had a significant score for anxiety – 18 (pathologic over 11) and 7 for depression (absent) on the Hospital Anxiety and Depression Scale. He came from a numerous family, in which, according to his statement, he wasn’t shown or offered enough affection, especially from his father, that unfortunately died one year before in a car crash. During all his childhood he was in a permanent race to be accepted by those around him.
He was very exigent with himself with the purpose of always rising above others’ expectations. In fact, his first consultation was a year before, for similar problems, when he was recommended treatment with 20 mg of fluoxetine for 3 months, 0,50 mg of alprazolam for two months, with a slow decrease in dosage, and a method to control breathing (breathing in three steps – maximal inspiration – 4 seconds, Valsalva manoeuvre – 4 seconds and forced expiration – 4 seconds) which he had to do three times per day, outside the anxiety periods, and in more difficult times. His evolution was oscillating, having relatively good moments or moments of high anxiety. Considering this situation, it was decided to approach the case from a religiously augmented REBT point of view in the last meeting.

We present the most important moments of the session (T: therapist, A: Antony):
“T: What determined you to come back to my office?
A: The same anxiety state I’ve told you before, that appears in the Jesuit community, when I am observed by others, especially by my superiors. I feel dizzy, I have palpitations, a lack of air and an undefined bad feeling. I think that I cannot meet the expectations of my superiors and my other colleagues.
T: Your problem is not mainly caused by your superiors’ expectations, but by the way you interpret situations.
A: I think you are right! I often thought about it, but I wasn’t sure if these worries are my “own imaginary constructs”.
T: It is good to realize what your own interpretations are concerning reality. I understood that you are a Philosophy student. I suppose you have studied about stoics and epicureans. As we both know, they sustain that things per se are not important, but our interpretations of them.
A: That is correct!
T: Starting from what these wise men said, a very simple and efficient mean of therapy was created by an American psychotherapist, Albert Ellis, the ABC model. We note with A all the events, situations, thoughts or imaginary elements that we suppose produce our suffering or make us feel disagreeable. We will take as an example what you have told me before. At A (situation), I’ve noted the moments where you are in the Jesuit community, especially in the presence of your superiors, that can observe you. At C (emotional consequences) I’ve noted the anxiety you were talking about, and which you thought, up until now, that it was a consequence of A. At B (interpretation) I’ve noted what you told me you are thinking in those moments: that you cannot raise to the level of your superiors’ expectations and, as a consequence, you will not be appreciated by them (table 1). T: This relatively simple model shows how not A determines C, but rather B determines C, otherwise said: not the fact that you are in the presence of your superiors and your colleagues, who can observe your behavior, induces anxiety, but the way in which you think “it is terrible” that you are not able to rise to their expectations and that you MUST, at any cost, be appreciated all the time. You have told me the same thing, but that you had some doubts about the correctitude of your interpretation.

You interpreted that “it is terrible” that you cannot rise all the time to the level of your superiors’ expectations and that “I will not be appreciated by them because I HAVE TO BE APPRECIATED BY OTHERS permanently”. You said that you are part of the Catholic Order of the Jesuits, which is also called: “Jesus’ Society”. Was our lord Jesus Christ appreciated by everybody all the time? Although he was Man – God and He did only good deeds on this Earth, He was betrayed by one of His closest disciples, Judas, the Iscariot, and by the people that acclaimed Him not long before, when He entered Jerusalem. Despite all this, Jesus said: “Father, forgive them, because they know not what they do.” No one is above our lord Jesus Christ! So, we cannot pretend for everybody to appreciate us!
A: Yes, I agree!
T: How would you feel if you reformulated it like this: I would like to be appreciated by my superiors all the time, but I know this is not possible?
A: I would be dissatisfied and a little worried, but not anxious.
T: Let’s analyze another problem you are dealing with.
A: The exam session is around the corner with six hard exams and I am afraid that I will not pass one of them. If I fail, that means I am a loser and I am not worthy of people’s appreciation.
T: Let’s apply the ABC model in this situation. What would the A be?
A: The upcoming exams. T: Ok, and the C? A: I have a terrible fear of failure. T: Ok, and the B? A: If I fail an exam, I am a loser and the others will not appreciate me!
T: In other words, THEY HAVE TO APPRECIATE ME! Do you think it is okay to judge ourselves globally according to just one less performant behavior or just for one failure? Let’s take an example of an irrational way of thinking connected to a hurried generalization about a regrettable action. Let’s take Saint Peter as an example! On whose foundation, Jesus Christ built the entire Church, he is considered the First Pope! As we all know, the night Jesus was sold for 30 pieces of silver in the Gethsemane garden by Judas, Peter betrayed Him three times by denying Him. If we were to think like you do, that would mean Peter is a traitor and a coward, that cannot be trusted and doesn’t deserve appreciation from others. Despite all of this, Jesus did not think like this, and invested Peter with such an important role. In the same way, Peter recognized his weakness with humility, continuing God’s work at Jesus’ urge: “But take heart! I have overcome the world!”.
A: Extraordinary! It is the exact theme of today’s lecture in our community!
T: So, it is not correct to consider ourselves losers for a failure. Life is a struggle, being filled with asperities and obstacles that we can sometimes overcome or not. On the other hand, Jesus has taught us to wear our cross with dignity. How could you think rationally about your exams? A: Anyone can fail an exam, but this does not automatically mean that he is a loser. On the other hand, you cannot be appreciated all the time by everybody. The Bible also says: “no one is a prophet in his own land”.
T: It is a very good wording! And how do you feel now, if you think differently? A: I think I am only a little bit stressed by the exams, but this will motivate me to be better prepared to pass them!
T: I would suggest keeping a diary where you can write daily in the next table, as a homework. (table 2) The evolution of the case was favorable due to cognitive restructuring using REBT with religious elements, adequate to the client’s religion

Similar results were obtained by Koening et al. (2015) and Pearce et al. (2016), who compared intervention with CBT with religious elements vs. standard CBT in major depression and in somatic disorders, demonstrating the superiority of the first one [11,12]. Out of the 10 irrational ideas enumerated by Ellis and Harper in the paper titled: “A new guide for a rational living” (2007), the client whose case has been described above had the most important one, that is: “I have to be loved and approved by all the persons that I consider significant”. Most people enjoy affection and approval, and it is good to have them, but you can live without them. People can hurt themselves by following the impossible ideal to be loved by everybody and by being constrained to live by other people’s standards, dominated by the imperatives of:
Must, Should, Ought. Also, the client presented another irrational idea: “I must not fail”, believing that he permanently has to prove maximum competency and according results. In fact, no human being is capable to realize everything he proposes to do. Our client also “catastrophized”, foreseeing his failure in the exam that generated anxiety.
CONCLUSIONS Applying REBT techniques augmented with religious elements were beneficial in treating a him. Adequate examples, especially when disputing irrational beliefs, are essential for the success of therapy. By adapting the intervention in this way, we favour the therapeutic relationship, which is essential for a successful therapy.

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