Flora: A Case of Severe Depression and Treatment with Rational Emotive Behavior Therapy
My Head of Department and Mentor, Dr. Muhammad Ajmal in Lahore, Pakistan, introduced me to REBT concepts in the early 1970s when I was completing my Masters in Psychology. Later, I had the opportunity to be a Fellow at the Albert Ellis Institute in the mid 1970s. The training at the Institute helped me grow up, and I started using the RET (as it was then called) concepts to practice, both on myself and on my clients at the Institute. REBT is a “progressive modality,” where the client is shown through “active-directive counseling” that, no matter what age group you are, you can get out of your emotional misery not by ruminating and blaming your early upbringing, but by starting to take responsibility for your present behavior. The “core cause” of your misery resides, in the majority of cases, within you: the way you interpret the environ - ment, the beliefs you carry about yourself, about others, and about the environment around you. Take the example of Flora, diagnosed with moderate symptoms, with a life-long history of emotional disturbance and with 10 years of psychoanalytic treatment but no respite to her disturbance. Her depression was interpreted as the result of retroflexed hostility, which was first directed at others but then turned against her own self when the outer expression proved to be too guilt-provoking. This may be true in some cases, but this insight did not help Flora with her musturbation, feelings of inadequacy, low self-esteem, and her suicidal ideation. However, her above-average intellectual ability helped her acquire awareness about REBT from attending a few of Albert Ellis’ Friday-night workshops. Flora experienced a new surge of positive energy in herself when she met Ellis for individual therapy. She learned that, despite the fact she was now 48 years old, she had hope of overcoming her emotional disturbance by questioning and challenging her embedded conscious and unconscious irrational ideas, which were the root cause of her disturbance. Ellis systematically explained her problems as twofold, the primary being her life-long anxiety, and unexpressed anger at others and herself, and the secondary being her depression and suicidal ideation due to her primary problems. Initially, and very aptly, Ellis focused on Flora’s depression and suicidal ideation about the life-long suffering she experienced owing to her performance and discomfort anxiety. Her need for competence, her demand for guarantees, and her low frustration tolerance led to her present disturbance. Ellis then systematically taught
her to change her demands to strong preferences. Initially, he helped her to stop putting herself down for feeling inadequate in not being able to tackle her anxiety problems. He helped her to learn to live with her anxiety as a bad habit. Later, he systematically, using his “assertive didactic counseling style,” helped her to develop “unconditional self-acceptance” (USA) and also helped her to increase her tolerance for frustrationno matter how she performed. Consequently, after 12 sessions spread over a period of four-and-a-half months, Flora felt a new “homeostasis,” which she had not experienced in 10 years of her earlier psychoanalytic treatment. Ellis attacked her problem on all the three fronts: cognitive, emotive, and behavioral. She started to feel sorry and disappointed about her feelings of anxiety-but not depressed for having them once she developed USA. Later, Ellis helped Flora deal with her life-long problem of anxiety and unexpressed anger. With REBT, her feelings of inadequacy and her original anxiety were remarkably reduced. Ellis is sensitive to the emotional needs of Flora, and in his interaction with her he explains how disturbed she is, but at the same time he shows her hope and confidence that she could reduce her disturbance if she puts in hard work. For this she would have to actively dispute her unrealistic thoughts and combat her disturbance at all levels, including thinking, feeling, and behavior, by putting herself in the driver’s seat, until she starts believing in the rational thoughts based on desires and preferences, stops her musturbation and the self-blame game, and starts striving for realistic long-term goals based on her abilities, interests, and resources.