Cognitive Behaviour Therapy

ISSN: 1650-6073 (Print) 1651-2316 (Online) Journal homepage: http://www.tandfonline.com/loi/sbeh20

Rational emotive behaviour therapy in high

schools to educate in mental health and empower
youth health. A randomized controlled study of a
brief intervention

Gry Anette Slid & Hans M. Nordahl

To cite this article: Gry Anette Slid & Hans M. Nordahl (2016): Rational emotive
behaviour therapy in high schools to educate in mental health and empower youth health.
A randomized controlled study of a brief intervention, Cognitive Behaviour Therapy, DOI:
10.1080/16506073.2016.1233453

To link to this article: http://dx.doi.org/10.1080/16506073.2016.1233453

Published online: 28 Oct 2016.

Submit your article to this journal

Article views: 91

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=sbeh20

Download by: [University Catolica Portuguesa] Date: 22 February 2017, At: 08:04
Cognitive Behaviour Therapy, 2016
http://dx.doi.org/10.1080/16506073.2016.1233453

Rational emotive behaviour therapy in high schools to

educate in mental health and empower youth health.
A randomized controlled study of a brief intervention
Gry Anette Slida,b and Hans M. Nordahlb,c
a
Domain for Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway; bDepartment
of Psychology, The Norwegian University of Science and Technology, Trondheim, Norway; cDepartment of
Neuroscience, The Norwegian University of Science and Technology, Trondheim, Norway

ABSTRACT ARTICLE HISTORY

Rational emotive behaviour therapy (REBT) is effective in reducing Received 13 April 2016
distress in several target groups. No other study has tested the mental Accepted 3 September 2016
health effects on adolescents in a high school setting while expanding KEYWORDS
a Cognitive Behaviour-based therapy, REBT, into the concept of mental Self-esteem; hope; anxiety;
health literacy. The format of the ABC model, which is an important depression; REBT
element of REBT, functioned as a working manual in and between
three sessions. This study tested whether knowledge and practical
use of the ABC model increased self-esteem and hope, and reduced
symptoms of anxiety and depression, and dysfunctional thinking.
Sixty-two high school students with subclinical levels of anxiety
and depression were randomly allocated into three groups; three
individual REBT sessions, or three individual attentional placebo
(ATP) sessions or no sessions (control). However, dysfunctional
thinking, self-esteem and hope were not measured in the control
group. Repeated measures with ANOVA and t-tests were conducted.
Both REBT and ATP significantly reduced symptoms of anxiety and
depression, but only REBT was significantly different from the control
group at the six-month follow-up. Only REBT significantly reduced
dysfunctional thinking, and both REBT and ATP significantly increased
self-esteem and hope. REBT had both an immediate and a long-term
effect. The findings show the potential positive effects of educating
well-documented psychological techniques as ordinary education in
school. Further research might contribute to decide whether or not to
change the school system by enclosing mental health literacy classes
for all students.

Introduction
Depression and anxiety are common in adolescents. As early symptoms of depression often
occur in childhood or adolescence, adolescents are an important target group for preventing
elevated symptoms of anxiety and depression (Costello, Mustillo, Erkanli, Keeler, & Angold,
2003; Merikangas et al., 2010). One in six adolescents report suicidal thoughts, which are
strongly associated with symptoms of anxiety and depression (Strandheim et al., 2014). Up

CONTACT Gry Anette Slid gasaelid@online.no, grsa@fhi.no

2016 Swedish Association for Behaviour Therapy
2 G. A. Slid and H. M. Nordahl

to 80% of adolescents with mental health problems are not treated (Zachrisson, Rdje, &
Mykletun, 2006). There is perceived discomfort discussing mental health issues and stigma
associated with mental illness which adolescents seem to be highly vulnerable to (Corrigan,
2005; Gulliver, Griffiths, & Christensen, 2010; Pescosolido et al., 2010).
However, the World Health Organization (WHO) defines mental health to be more than
the absence of illness, and asserts that health promotion is a more effective strategy than
illness prevention in developing and maintaining population health (WHO, 2004). For
example, attitudinal and cognitive variables (e.g. hope) predict outcomes above and beyond
psychopathology (Hagen, Myers, & Mackintosh, 2005). The assessment of hope is important
because it correlates with an individuals perceived sense of success at achieving goals in
the present, past and future (i.e. self-efficacy), and perceived abilities to create methods to
achieve goals (i.e. waypower) (Snyder, Ilardi, Michael, & Cheavens, 2000; Snyder, Lopez,
Shorey, Rand, & Feldman, 2003). Individuals with high self-esteem might adopt active
coping strategies focused on problems, whereas individuals with low self-esteem might
adopt passive-avoidant coping styles focused on emotions (Thoits, 1995). Low self-esteem
is associated with depression (Bettschart, Nunez, Bolognini, & Plancherel, 1994), anxiety
and unsuccessful coping strategies (Houston, 1977; Seiffge-Krenke, 1995).
Self-esteem is the positive or negative evaluative perception on oneself. Self-esteem is
derived from a global rating of the self on the basis of the current and past traits. As such,
the self is rated as good when good, and rated as bad when bad things are done accord-
ing to socially approved rules. However, the REBT solution to the problem of self-rating
is that people can change their internal dialogue towards unconditional self-acceptance
and consider themselves valuable, despite bad or good deeds, thoughts or actions (e.g.
accomplishments at school).
There is a lack of research on how to strengthen adolescents in the school setting to be
more resilient and empowered in order to meet the challenges in society and in work life.
There is also a lack of studies on how innovative research may contribute to the development
of high-quality education in high schools. Despite the vast number of studies on positive
psychology constructs within the past decade, few have assessed changes in adolescents
hopeful thinking and self-esteem as a result of a brief intervention in a school setting.
This study examined the effects of educating students with subclinical levels of anxiety
and depression about the ABC model in rational emotive behaviour therapy (REBT). REBT
attempts to change an irrational and biased perception of reality to a rational and adaptive
one. The ABC model of REBT describes how thoughts, feelings and behaviour are interre-
lated and a change in irrational thoughts can change feelings and behaviours (Ellis, 1979).
Thus, the goal is to achieve a different behavioural or emotional reaction by modifying the
cognitions activated by various events (Broder, 2000).
Beliefs are evaluative views that are either rigid or flexible, and extreme or non-extreme.
Irrational beliefs take form of musts, absolute should, have-tos and so forth. Such demand-
ingness adheres rigid premises (e.g. I must never make a mistake) in contradistinction to
flexible thinking (e.g. I do not want to do mistakes, but if I do, it is not the end of the word).
Awfulising everything to be more than 100% bad is illogical while non-catastrophising is
a more logical belief (e.g. It`s bad, but its not terrible). Low frustration intolerance is
not being able to endure situations or have any happiness at all if the perceived demands
exist, while high frustration tolerance is the opposite (e.g. I don`t like it, but I can bear it).
Global evaluation or depreciation of themselves, others and/or life conditions (e.g. If I fail
 Cognitive Behaviour Therapy 3

at something important to me, then I am a failure!) is the opposite of unconditional accept-

ance, which includes to accept themselves and others as fallible human beings (Dryden,
DiGiuseppe, & Neenan, 2003).
Evidence exists for the efficacy of REBT as an effective treatment for a variety of disorders
(Banks & Zionts, 2009; Gonzalez et al., 2004; Lyons & Woods, 1991). In addition, there
are several studies on rational emotive education (Hajzler & Bernard, 1991; Kachman &
Mazer, 1990; Laconte, Show, & Dunn, 1993; Rosenbaum, McMurray, & Campbell, 1991;
Rudish & Millice, 1997).
This study is the first study, to the best of our knowledge, which expands the ABC model
in REBT into the concept of mental health literacy. The theoretical framework of this study
is based on the Ellis work on REBT (Ellis, 1985, 1994). The main idea in REBT is that psy-
chological disorders are related to the process of thinking and interpretation about events.
With an emphasis on dealing with the problems in the present, the individuals are taught
how to examine and challenge their unhelpful thinking which creates unhealthy emotions
and self-defeating strategies and behaviours. We expect that this framework is also effective
on adolescents, irrespective of being diagnosed with a mental disorder. Mental health liter-
acy has been carried out throughout the world, but few have been evaluated (Jorm, 2012).
Concrete psychological techniques are usually reserved for individuals in treatment in
the mental health system or individuals at risk of developing mental illness. Unlike physical
health training (e.g. gymnastics), mental health training occurs only exceptionally in high
schools. In this study, the knowledge of psychological techniques is labelled as common
knowledge for self-empowerment, on par with knowledge of how to strengthen muscles
(e.g. in gymnastics). The study has two purposes: first, to educate in mental health and
second, test the benefits of a short-term programme for adolescents in learning mental
health techniques in a school setting. The adolescents received a sheet of paper showing
the ABC model, which functioned as a manual while the adolescents were educated about
the essence of the model. The adolescents were provided with homework assignments
between every session.
The current study reports a randomised controlled trial of three groups: REBT, attentional
placebo (ATP) and a control group (which received no sessions). There were only three
individual sessions in REBT and three individual sessions in ATP. It was hypothesised that
the knowledge and the practical use of the ABC model in the REBT group would reduce
dysfunctional thoughts, symptoms of depression and anxiety and increase hope and self-
esteem. It was also hypothesised that greater improvements would be seen amongst the
REBT group than the ATP group, and that the REBT group would be significantly different
than the control group at the six-month follow-up.

Methods
Participants and selection
Three hundred and seven high school students from the same school, in a normal adolescent
population in Norway, received the same brief introduction to the study in the classrooms,
and were screened using the Hospital Anxiety and Depression Scale (HADS). The students
ranged in age from 16 to 19 years. They were informed about the normality of having
mental strains, about the random selection process and that it was voluntary to write their
4 G. A. Slid and H. M. Nordahl

Figure 1.Flow diagram.

name and telephone number on the form. All adolescents were invited to participate. The
questionnaires were shuffled, randomly assigning participants to one of the three groups:
21 participants in REBT, 21 in ATP and 20 in a control group.
The selection process is shown on a flow diagram, Figure 1. There were an equal number
of girls and boys in each group, but differences in gender were not taken into account in the
randomisation process. Only two participants in the study had an ethnic minority back-
ground, excluding race as a variable. With a probability level of .05, using a two-sided test
and with an estimated effect size from pre- to post-treatment of .60 (moderate) and 21 in
each group, the sample had a statistical power of .86, which was acceptable (Cohen, 1988).

Ethical considerations
Participants received an information letter and a letter of consent stating that their partici-
pation was voluntary and that they could withdraw from the study whenever they wanted.
Parents signed the consent for participants who were younger than 18years. This study was
approved by The Regional Committee for Research Ethics in south-east Norway.
 Cognitive Behaviour Therapy 5

The participants received a sheet showing the ABC model, and the model was translated
into Norwegian with permission (Dryden, 2005).

Study design and procedure

The study was based on a comparative prepost design with six-month follow-up. ANOVA
and t-tests were conducted and within-group effect sizes were calculated. The REBT group
participated in three individual sessions in which they learned to apply the ABC model to
problems and adverse situations, and were instructed to use alternative responses to thinking
and behaviour. The second group attended three individual ATP sessions and were given the
opportunity to ventilate and talk about their problems, but received no advice or directions
for solving their problems. The third group served as a control without any counselling
and were asked to complete the same questionnaires at pre and post as the REBT and ATP
groups. Each individual session lasted 45 min, and approximately two months elapsed
between sessions. Follow-up was conducted one year after the initial screening (four to six
months after the last session for the intervention groups).
Symptoms of anxiety and depression were measured at the screening (pre) and at the
follow-up (post) in the classrooms. Self-esteem, hope, dysfunctional thinking and symptoms
of anxiety and depression were measured at the start in the first and second sessions and in
the end of the last session. A satisfaction evaluation was administered on the last session.
Due to class time constraints, the control group was only assessed with Hospital Anxiety
and Depression Scale (HADS) and not the other measures.

The REBT intervention

There are steps which are used in the evaluation of clinical or research applications for
effective REBT practice (Dryden et al., 2003; Dryden, Beal, Jones, & Trower, 2010). This
process is presented, but with some flexibility. The first author is certified in REBT from the
Albert Ellis Institute in New York and she conducted all sessions in this study. The thera-
pist was supervised during the whole trial, and compliance with protocol and competence
was assessed by an expert therapist (HMN). Based on video recordings, the sessions were
evaluated post hoc using parts of the REBT competency scale (Dryden et al., 2010). The
adherence or treatment fidelity of the brief intervention in the current study was measured
by an independent assessor (HMN). A checklist of the six major tasks in the Brief interven-
tion was used to measure competency and adherence. The mean rate was 94% with a range
of 83100%. The main tasks to be assessed in the checklist were: (1) identify distressing
emotion or behaviour, (2) collaborative goal setting, (3) assessing negative emotion or
behaviours, (4) applying the ABC format, (5) challenge irrational beliefs and (6) assigning
homework.
In the first REBT session, the participant was asked what problem or life adversity he/
she would like to focus on first. The focus of the first session was to identify a disturbing
and distressing emotion or behaviour. After the participant had identified feelings or behav-
iours he/she would like to change, the participant and therapist agreed on a goal. When the
participant had exemplified the target problem, the therapist assessed the negative emotion
or behaviour (C) and the activating event (A). However, the therapist did not distinguish
6 G. A. Slid and H. M. Nordahl

between the problem as defined goal and the problem as assessed goal, but potentially
emotional problems were assessed.
Shortly after the introduction in the first session, the therapist introduced the REBT
self-help form (ABC model) to the participant, and the student received a sheet of paper
showing the ABC model which functioned as a manual. The therapist and the participants
discussed the beliefs or thoughts (B) (Its awful I made the mistake), challenged the beliefs
(D) (Why is it awful I made the mistake?) and then more logically and rationally answered
the Ds (E). The therapist worked through the ABC model with the participants example,
explaining the concepts of irrational beliefs, rational beliefs, dogmatic demands, frustra-
tion tolerance and life acceptance. The BC connection was the main focus, as well as the
difference between irrational and rational beliefs.
The core of the last sequence in the first session and of the second and third sessions
was to challenge whether the belief was helpful or self-defeating, and questioning irrational
beliefs. The participant was askeddoes this belief make sense? The therapist and the
student replaced the irrational beliefs (D) with effective new philosophies (views) (E). In
the second and third sessions, the therapist was teaching more profoundly the difference
between irrational and rational beliefs, mostly on demandingness versus flexible thinking
(e.g. I must get outstanding grades, otherwise I am a failure into: I work hard and I will
continue to work hard, but there is no reason why I must get what I want). The focus was to
express the preferences into wishes and desires instead of dogmatic demands, and increase
frustration tolerance, non-catastrophic thinking and not globally rate others or themselves.
The participants strived for more rational thinking when experiencing an activating event;
I dont like it, but I can stand it.
All REBT group participants received homework assignments after every session, and
they were expected to implement what they had learned from the model into practise. The
homework assignment was to record on the sheet of the ABC model the next time the
student felt distressed. During the second and third sessions, the student and the therapist
discussed potential difficulties with filling in the D, E and E sections of the form.

Measures
Depression and anxiety were assessed using the Hospital Anxiety and Depression Scale
(HADS), a test that contains one anxiety scale (HADS-A) and one depression scale
(HADS-D). Each section consists of seven statements ranked from no symptoms (0) to high
symptoms (3), with a maximum possible total score (HADS-T) of 42; a low score implies
a low degree of anxiety and depression. My head is full of concerns is an example of a
HADS-A statement, and I can laugh and see whats funny about the situation is a HADS-D
statement. HADS is reported to have high validity for anxiety and depressive symptoms, and
satisfactory reliability for both the total score and each subscore (Spinhoven et al., 1997).
Based on Snaith and Zigmonds recommendations and manual of defining cut-off values,
HADS can give an indication of mental disorder: 07 is normal range, 813 mildly affected,
1416 moderate and 17 or more indicates a severe level. Thus, between 8 and 13 should
suggest a subclinical, but elevated, level of symptoms. HADS demonstrated moderate to
high validity and reliability in various translations (Bjelland, Dahl, Haug, & Neckelmann,
2002). The item analysis in the current study showed moderate to high reliability, with a
Cronbachs alpha ranging from .69 to .80 across different time points.
 Cognitive Behaviour Therapy 7

Hope was evaluated using the Herth Hope Index (HHI) which defines hope as a multidi-
mensional dynamic life force that involves an expectation of mastering something (Dufault
& Martocchio, 1985). HHI contains 12 statements with response options from totally agree
(1) to totally disagree (4). Statement numbers 3 and 6 are negatively formulated, requiring
the answers to be altered before summing. A high score implies high hope. Examples of
these statements include I perceive life positively and I feel totally alone. HHI has been
shown to have satisfactory validity and reliability and the scale has shown high reliability
(.81) in other Norwegian samples (Wahl et al., 2004). Cronbachs alpha estimates from the
measured time points in the present study varied from moderate to high: .68 to .83.
The Rosenberg Self-Esteem Scale (RSES) measures self-esteem in 10 parts, 5 positively
formulated and 5 negatively formulated. The respondents are asked to indicate the degree
to which they agree with the statements, from very much disagree (1) to very much agree
(4). When the negative questions are inverted, high scores indicate high self-esteem. An
example of a statement is: I am pleased with myself and I can manage as well as anybody
else. The mean reliability (Cronbach alphas) across 53 nations is high: .81 (Schmitt &
Allik, 2005). Item estimates in the present study showed moderate to high reliability, with
Cronbachs alpha ranging from .76 to .88 across different time points.
Dysfunctional thinking was evaluated with the Dysfunctional Attitude Scale (DAS-A);
this test contains 40 items that are assessed with a seven-point Likert scale from totally
agree to totally disagree. The minimum score is 40 and the maximum is 280. High scores
indicate an assumption about vulnerability, self-critical thinking and depression proneness.
DAS statements include: To make mistakes is okay, because I can learn from them and
Happiness is dependent more on other people than on myself . DAS has demonstrated
high validity and reliability (Olinger, Kuiper, & Shaw, 1987). The Norwegian version of the
Dysfunctional Attitude Scale has shown Cronbachs alpha of .85, indicating high reliability
(Chioqueta & Stiles, 2004). Cronbachs alpha in the present study varied from .88 to .93,
which is high reliability.
In measuring the irrational processes, we should have chosen any of the classical meas-
ures of the irrational/rational processes directly targeted by REBT. However, we wanted to
utilities a broader set of measures in which REBT is incorporated. A wider applicability of
the DAS may facilitate future comparisons with other cognitive behaviour therapy (CBT)
studies.
The anonymous session evaluation required the participants to reflect on their experi-
ences, and the answers were scored with a five-point Likert scale. The evaluation form also
asked whether the participants satisfaction with the sessions was excellent, very good,
good, dont know, bad, very bad or extremely bad. We then asked the participants
whether they were familiar with the links between feelings, thoughts and behaviour. The
participants could also identify positive or negative elements of the experience, and were
encouraged to write other comments.
The REBT competency scale is a measure for evaluating the level of therapist competency
in REBT (Dryden et al., 2010). It is based on a specific model of the practice of REBT and
the standard protocol is based on the Dryden et al. (2003) treatment protocol. The REBT
competency scale consists of 22 steps and in the instructions, the assessor should rate
adherence on all tasks.
8 G. A. Slid and H. M. Nordahl

Statistical analysis
The data were analysed using repeated measures with ANOVA and Bonferroni correction
as post hoc test for comparisons between data groups. We report the main effects of the
findings and the interaction between time and group. Paired sample t-tests and independent
t-tests are utilised to test effects within the groups, test for differences between the groups
and test which of the groups (e.g. REBT and ATC) are significantly different from the con-
trol at post and at pre to post. The sample sizes are calculated for differences between two
independent means, within-group effect sizes were calculated using Cohens d formulae
(Cohen, 1988). Missing data (at post: REBT: 2, ACT: 4; Control: 0) were not treated and
utilised in the analysis (Table 1).

Results
Anxiety and depression
We observed a significant change in the HADS scores between the pre- and post-test [F (1,
53) = 33.38, p<.05]. The effect of time was nevertheless dependent on the groups because
there was a significant interaction between time and group [F (2, 53) = 4.59, p<.05]. T-tests
showed that the REBT group significantly differed from the control group at post-test
[t (37) = 2.15, p < .05]. However, the ATP group did not significantly differ from the
control group. Furthermore, significant within-group changes between pre-test and post-
test in anxiety and depression symptoms occurred in REBT [t (18) = 5.79, p<.05] and ATP
[t (16) = 3.44, p<.05] groups.
ANOVA revealed a significant effect over the five HADS measurements [F (4, 136) =
17.99, p<.05], but according to t-tests, there were no significant differences between the
REBT and ATP groups.
We employed Cohens (1988) scale of effect sizes (d): .0.2, no or low effect; .3.5, small or
some effect; .6.8, moderate; and .8 and above, high effect. REBT had a high effect (d=1.53)
on anxiety and depression symptoms from pre-test to post-test, measured by HADS. ATP
also had a high effect from pre-test to post-test (d=.99). There is a moderate controlled
effect size between REBT and the control group at post-test (d=.70), and a small effect size
between ATP and the control groups (d=.42).
None of the participants reported negative effects of the intervention.

Dysfunctional thinking
There was a significant effect on dysfunctional thinking over time [F (3, 96) = 5.11, p<.05].
Dysfunctional thinking was nevertheless only significantly reduced in the REBT interven-
tion: from the first to the second session, [t (19) = 3.56, p<.05], from the first to the third
session, [t (19) = 4.33, p<.05] and the first session to the follow-up, [t (18) = 3.40, p<.05].
There was some effect of the REBT group on dysfunctional thinking (d=.45).

Hope
Time had a significant effect on hope [F (3, 102) = 5.99, p<.05]. T-tests indicated no sig-
nificant differences between the REBT and the ATP groups, but both groups had significant
Table 1.Mean sums of scores (M), standard deviation (SD) and the number of participants (n) in the REBT,- ATP and NTC groups with repeated measures by HADS, HHI,
RSES and DAS.
Screening (pre-test) First session Second session Third session Follow-up (post-test)
REBT ATP NTC REBT ATP REBT ATP REBT ATP REBT ATP NTC
HADS M 12.47 12.17 11.70 9.84 9.35 9.05 8.52 7.89 7.70 7.21 8.47 10.60
SD 3.33 3.43 3.62 4.18 3.98 4.10 4.10 5.07 3.67 3.53 4.00 5.91
n 21 21 20 21 21 20 19 20 19 19 17 20
HHI M 37.13 38.02 37.37 39.11 39.91 39.31 39.31 40.11
SD 3.26 4.05 3.41 4.38 4.12 4.66 4.23 4.92
n 21 21 20 19 20 19 19 17
RSES M 26.33 27.47 28.20 28.57 28.50 29.21 28.94 29.00
SD 2.83 3.66 3.01 3.48 3.77 4.31 3.42 4.31
n 21 21 20 19 20 19 19 17
DAS M 113.54 115.14 102.84 115.98 98.26 111.47 101.42 111.42
SD 28.69 15.59 24.15 23.67 26.60 22.88 25.48 31.24
n 21 21 20 19 20 19 19 17
Notes: SD - Standard deviation; REBT - Rational Emotive Behaviour Therapy; ATP - Attentional Placebo; NTC - No Treatment Control; HADS - Hospital Anxiety and Depression Scale; HHI - Herth Hope
Index; RSES - Rosenberg Self-Esteem Scale; DAS - Dysfunctional Attitude Scale.
Cognitive Behaviour Therapy
9
10 G. A. Slid and H. M. Nordahl

increases in hope. In the REBT group: from the first session to the third session, [t (19) =
2.65, p<.05], and from the first session to the follow-up; [t (18) = 2.57, p<.05]. In the
ATP group: from the first session to the follow-up, [t (16) = 2.49, p<.05].
REBT had a small to moderate effect on the degree of hope from the first session to
post-test (d=.58). In contrast, ATP had hardly no effect (d=.12).

Self-esteem
There was a significant effect over time for self-esteem (RSES) [F (3,102) = 12.04, p<.05].
T-tests suggested that there were no significant differences between REBT and the ATP
interventions, and both groups had significant effects on self-esteem. In the REBT group:
from the first to the second session, [t (19) = 3.71, p<.05], from the first to the third
session, [t (19) = 4.27, p<.05] and from the first session to the follow-up [t (18) = 5.24,
p<.05]. In the ATP group: from the first to the third session, [t (18) = 3.12, p<.05], and
from the first session to the follow-up, [t (16) = 3.58, p<.05].
RSES displayed a moderate to strong effect on the degree of self-esteem in the REBT
group (d=.83), while the ATP group had a small effect (d=.38).

Participant self-evaluation
The REBT and ATP groups received an identical evaluation form. Participants in the REBT
group reported that it was interesting to learn how to gain more perspective on their prob-
lems. The participants in the ATP group overall reported that it felt good that someone
wanted to listen to them. Thirteen (65%) participants in the REBT group and 9 (47%) in the
ATP group responded excellent on the participants satisfaction with the sessions. Six (30%)
in the REBT group and five (26%) in the ATP group answered very good. One participant
(5%) and five (26%) responded good in the REBT group and the ATP group, respectively.
None of the participants responded dont know, bad, very bad or extremely bad.
When the REBT group was asked if they already knew about the links between thoughts,
feelings and behaviour as illustrated in the ABC model, 18 of the 20 (90%) reported that
they had been unaware of this.

The REBT competency scale

As the current study is only a three-session intervention trial of the ABC model, only half
of the steps were relevant for the assessment of the therapists performance. The average
levels of competency could range from 1 very poor to 6 excellent. For the various steps
across three cases, the following scores were reported: step 15.6; step 24.6; step 46.0;
step 53.3; step 64.0; step 104.6; step 124.0; step 174.6; step 203.3; and step 214.6.
The average competency score based on these 10 steps was 4.5/6, indicating an adequate
to good performance.

Bonferroni correction
We employed post hoc analyses with the Bonferroni correction adjusting for multiple anal-
yses. However, overall, the results with the Bonferroni correction were the same.
 Cognitive Behaviour Therapy 11

Discussion
This is, to our knowledge, the first study of a brief intervention of REBT in mental health
literacy which seeks to educate and empower adolescents mental health in a high school
setting.
There were no significant differences between the groups on any of the measures at
pre-treatment. Both REBT and ATP significantly reduced symptoms of anxiety and depres-
sion at the six-month follow-up; however, only REBT was significantly different from the
control group. There was a significant reduction in dysfunctional thinking in the REBT
group, but not in the ATP group. Furthermore, hope and self-esteem significantly increased
in both the REBT and the ATP groups. At the last session, 90% of the adolescents (18 out of
the 20 participants) in the REBT group reported not having had any previous knowledge
of the links between thoughts, feelings and behaviour.
The effect size at post is relevant for the hypothesis, as only the REBT group is signifi-
cantly different than the control group at the six-month follow-up. Further, effect size for
the first session and third session shows that the knowledge and the practical use of the ABC
model in the REBT group have reduced dysfunctional thoughts, symptoms of depression
and anxiety and increased hope and self-esteem. There are greater improvements (the effect
size is stronger and the findings are significant) in REBT, even though ATP had significant
effect over time (pre to post).
The findings indicate that educating adolescents in the ABC model in three sessions
empowers mental health by increasing hope and self-esteem, and by reducing anxiety and
depressive symptoms and dysfunctional thinking. The ATP group showed that it is bene-
ficial for the adolescents to have a person who listens to them and to ventilate emotional
distress. However, overall, REBT had significantly larger effects than ATP on all outcome
measures, both in the short and long terms. Compared to the control group, only REBT
had a long-term effect on anxiety and depressive symptoms.
By a brief intervention of only three sessions, dysfunctional thinking was significantly
reduced in the REBT group, but not in the ATP group. This finding is in accordance with
the formulation of REBT theory that proposes that the mechanism of changing emotional
distress is to modify dysfunctional thinking. Reivich, Gilham, Chaplin, and Seligman (2005)
suggest that the understanding of the ABC model is essential because it is a concrete strategy
towards changing dysfunctional thoughts that are linked with emotions. Several studies have
reported high correlations between irrational beliefs and depression (Muran, Kassinove, &
Ross, 1989; Smith, 1989; Thyer, Papsdorf, & Kilgore, 1983).
Both REBT and ATP showed significant effects on hope and self-esteem, although REBT
had higher effect sizes. Empowering students to cope with challenges in society and in
work life is interpreted to be important for several reasons, e.g. the sense of hope is seen
as critical for successful functioning and adaptation (Snyder, 1994), and self-esteem cor-
relates with several positive mental health constructs, such as active positive coping styles
(Mantzicopoulos, 1990). Unconditional self-acceptance may change the negative self-rating
towards more healthy attitudes and coping styles. The individual fully and uncondition-
ally accepts himself whether or not he behaves intelligently, correctly, or competently and
whether or not other people approve, respect, or love him (Ellis, 1977, p. 101). The positive
effect from participating in the ATP group may be due to the ability to reveal problems,
and receive attention and emotional support. This is apparently important, and therefore
should be controlled for in all treatment trials.
12 G. A. Slid and H. M. Nordahl

At the last REBT session, almost all of the participants (90%) reported that they had been
unaware of the links between thoughts, feelings and behaviour. The acquired knowledge and
practice of the ABC model may have caused greater benefits from the intervention than the
ATP group. The effects of REBT may be long-lasting because of acquired knowledge and
practice of psychological techniques in dealing with their emotional distress.
REBT or CBT is usually accessible to patients in mental psychiatric care and incidences
of mental illness. These techniques do not represent common knowledge in high schools,
and thus should be more available. There are, however, several mental health programmes in
schools. Such programmes usually promote broader knowledge of the field of mental health.
This study may contribute evidence that educating students in core psychological techniques,
and even to the extent of only three sessions, may have positive and lasting effects.
However, if the knowledge of mental health is interpreted in the future as common
knowledge, education in the ABC model in REBT may be included in a broader mental
health class at school. The knowledge of mental health may in the future be perceived as
equally important as knowledge gained in other classes, e.g. gymnastics, maths and physics
classes. Further research might consider testing whether such well-documented psycho-
logical techniques are valuable knowledge for all students (including students who have
no symptoms of anxiety and depression), and test whether increasing accessibility to such
techniques might contribute to reducing social inequality in education and health. Larger
projects may utilise trained school nurses or school psychologists to provide all adolescents
with such knowledge through ordinary education in the classroom.

Strengths and limitations

This study has some strength. It shows that brief intervention using the ABC model in
subclinical samples in high schools may be useful. However, Lyons and Woods (1991)
reported that large effect sizes are related to therapy duration. It is however encouraging
that this study shows large effects at six-month follow-up and even moderate to large effects
after the sessions. Second, the randomised controlled design with three groups allowed us
to differentiate between a natural reduction in symptoms of depression and anxiety in the
control group and a reduction caused by the sessions in ATP or REBT. Third, in the present
study, attentional placebo effects (ATP) as well as time (controls) were controlled for.
The study has also some limitations. First, although the session evaluation was anon-
ymous, the participants may not want to provide poor ratings to the therapist. Second, it
may be argued that the sample size was at the low end. The statistical power of the analysis
was above .80 and this is sufficient to demonstrate differential change. Still, a larger sam-
ple should be tested in further explorations of this method. Third, while the participants
awareness and application of the ABC model seemed to be positive, there should have been
a longer follow-up period to examine the effects at 12months and beyond. Additionally,
we do not have data on whether the participants actually had done their homework assign-
ments, which might be relevant for explaining the long-term effect. However, at the second
and third sessions, the therapist and the participant discussed the homework assignment
(registration in the ABC form) and most of the participants were prepared. Fourth, there
is a limitation of the study that we did not include other measures than HADS in the
control group, as there might be lost important differences between the groups regarding
self-esteem, hope and dysfunctional thinking. Fifth, caution should be taken in addressing
 Cognitive Behaviour Therapy 13

the present study as a preventive intervention. We only have information about whether
REBT and ATP reduce emotional distress and dysfunctional thinking. The efficacy of a
prevention programme is measured by the expected protection through a time of elevated
risk in a normal adolescent population (Gillham, Shatt, & Freres, 2000). Thus, additional
follow-up evaluations would permit the examination of possible risk factors such as parental
divorce and death of a close friend. Ideally, the subjects should be followed through the end
of adolescence in order to demonstrate a preventive effect of education in the ABC model.
However, these aspects were beyond the scope of this study.
In conclusion, the current study showed that the ABC model in REBT can be utilised
as a working manual to empower adolescents mental health, even when the ABC model is
taught in a condensed short-term format of only three sessions. REBT seems to be effective
in terms of increasing hope and self-esteem, reducing dysfunctional thinking and symptoms
of anxiety and depression. The ATP group had positive effects, but REBT had larger effect
sizes and was significantly different from the control group. The positive ATP effect indicates
that young people should be presented with opportunities to discuss their problems. The
significant effect of REBT indicates that it may be even more important to acquire tools and
coping strategies to deal with daily problems and adversities. Further research should test
long-term effects of educating well-documented psychological techniques in the classroom
as ordinary education on all students, irrespective of symptoms of anxiety and depression.
Funding and grant-awarding bodies: No founding; the study is a thesis for the degree in
MSc in psychology (first author, Gry Anette Slid).

Disclosure statement
The authors have no conflicts of interest to disclose.

ORCiD
Gry Anette Slid http://orcid.org/0000-0003-3347-0749
Hans M. Nordahl http://orcid.org/0000-0001-9275-646X

References
Banks, T., & Zionts, P. (2009). REBT used with children and adolescents who have emotional and
behavioural disorders in educational settings: A review of the literature. Journal of Rational-Emotive
& Cognitive-Behavior Therapy, 27, 5165. http://dx.doi.org/10.1007/s10942-008-0081-x
Bettschart, W., Nunez, R., Bolognini, M., & Plancherel, B. (1994). Lestime de soi la pradolescence:
Une tude longitudinale [Regard of oneself as a pre-adolescent: A longitudinal study]. Nervure,
7, 2325.
Bjelland, I., Dahl, A. A., Haug, T. T., & Neckelmann, D. (2002). The validity of the Hospital Anxiety
and Depression Scale An updated literature review. Journal of Psychosomatic Research, 52, 6977.
http://dx.doi.org/10.1016/S0022-3999(01)00296-3
Broder, M. S. (2000). Making optimal use of homework to enhance your therapeutic effectiveness.
Journal of Rational-Emotive & Cognitive-Behavior Therapy, 18, 318. http://dx.doi.
org/10.1023/A:1007778719729
Chioqueta, A. P., & Stiles, T. C. (2004). Psychometric properties of the Norwegian version
of the dysfunctional attitude scale. Cognitive Behaviour Therapy, 33, 8386. http://dx.doi.
org/10.1080/16506070410023951
Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed). Hillsdale, NJ: Erlbaum.
14 G. A. Slid and H. M. Nordahl

Corrigan, P. W. (2005). On the stigma of mental illness: Practical strategies for research and social
change. Washington, DC: American Psychological Association.
Costello, E. J., Mustillo, S., Erkanli, A., Keeler, G., & Angold, A. (2003). Prevalence and development
of psychiatric disorders in childhood and adolescence. Archives of General Psychiatry, 60, 837844.
PMID: 12912767. http://dx.doi.org/10.1001/archpsyc.60.8.837
Dryden, W., DiGiuseppe, R., & Neenan, M. (2003). A primer on rational emotive behaviour therapy
(2nd ed.). Champaign, IL: Research Press.
Dryden, W. (2005). Correspondence by e-mail (The ABC model was translated into Norwegian with
permission).
Dryden, W., Beal, D., Jones, J., & Trower, P. (2010). The REBT competency scale for clinical and
research applications. Journal of Rational-Emotive & Cognitive-Behavior therapy. Retrieved from
http://www.springerlink.com/content/v2v2x84777650656/fulltext.pdf
Dufault, K., & Martocchio, B. C. (1985). Symposium on compassionate care and the dying exerience.
Hope: Its spheres and dimensions. The Nursing Clinics of North America, 20, 379391.
Ellis, A. (1979). The theory of rational emotive therapy. In A. Ellis & J. Whiteley (Eds.), Theoretical
and empirical foundations of rational emotive therapy (pp. 926). Monterey, CA: Brooks/Cole.
Ellis, A. (1985). Expanding the ABCs of rational-emotive therapy. In M. J. Mahoney & A. Freeman
(Eds.), Cognition and psychotherapy (pp. 313323). New York, NY: Plenum Press.
Ellis, A. (1994). Reason and emotion in psychotherapy (Rev. and updated). Secaucus, NJ: Birch Lane.
Gillham, J. E., Shatt, A. J., & Freres, D. R. (2000). Preventing depression: A review of cognitive-
behavioral and family interventions. Applied and Preventive Psychology, 9, 6388. http://dx.doi.
org/10.1016/S0962-1849(00)80007-4
Gonzalez, J. E., Nelson, J. R., Gutkin, T. B., Saunders, A., Galloway, A., & Shwery, C. S. (2004).
Rational emotive therapy with children and adolescents: A meta-analysis. Journal of Emotional
and Behavioral Disorders, 12, 222235. http://dx.doi.org/10.1177/10634266040120040301
Gulliver, A., Griffiths, K. M., & Christensen, H. (2010). Perceived barriers and facilitators to mental
health help-seeking in young people: A systematic review. BMC Psychiatry, 10, 113. http://dx.doi.
org/10.1186/1471-244X-10-113
Hagen, K. A., Myers, B. J., & Mackintosh, V. H. (2005). Hope, social support, and behavioral
problems in at-risk children. American Journal of Orthopsychiatry, 75, 211219. http://dx.doi.
org/10.1037/0002-9432.75.2.211
Hajzler, D. J., & Bernard, M. E. (1991). A review of rational-emotive education outcome studies.
School Psychology Quarterly, 6, 2749. http://dx.doi.org/10.1037/h0088242
Houston, J. P. (1977). Cheating behavior, anticipated success-failure, confidence, and test importance.
Journal of Educational Psychology, 69, 5560. http://dx.doi.org/10.1037/0022-0663.69.1.55
Jorm, A. (2012). Mental health literacy: Empowering the community to take action for better mental
health. American Psychologist, 67, 231243. http://dx.doi.org/10.1037/a0025957
Kachman, D. J., & Mazer, G. E. (1990). Effects of rational emotive education on the rationality,
neuroticism and defense mechanisms of adolescents. Adolescence, 25, 131145.
Laconte, M. A., Show, D., & Dunn, I. (1993). The effects of a rational-emotive affective education
program for high-risk middle school students. Psychology in the Schools, 30, 274281. http://dx.doi.
org/10.1002/(ISSN)1520-6807
Lyons, L. C., & Woods, P. J. (1991). The efficacy of rational-emotive therapy: A quantitative review of
the outcome research. Clinical Psychology Review, 11, 357369. http://dx.doi.org/10.1016/0272-
7358(91)90113-9
Mantzicopoulos, P. (1990). Coping with school failure: Characteristics of students employing
successful and unsuccessful coping strategies. Psychology in the Schools, 27, 138143. http://dx.doi.
org/10.1002/(ISSN)1520-6807
Merikangas, K. R., He, J. P., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., Swendsen, J. (2010).
Lifetime prevalence of mental disorders in US adolescents: Results from the National Comorbidity
Survey Replication-Adolescent Supplement (NCS-A). Journal of the American Academy of Child &
Adolescent Psychiatry, 49(10), 980989. http://dx.doi.org/10.1016/j.jaac.2010.05.017. PMID: 20855043.
Muran, J. C., Kassinove, H., & Ross, S. (1989). Irrational thinking and negative emotionality in college
students and applicants for mental health services. Journal of Clinical Psychology, 45, 188193.
http://dx.doi.org/10.1002/(ISSN)1097-4679
 Cognitive Behaviour Therapy 15

Olinger, L. J., Kuiper, N. A., & Shaw, B. F. (1987). Dysfunctional attitudes and stressful life events:
An interactive model of depression. Cognitive Therapy and Research, 11, 2540. http://dx.doi.
org/10.1007/BF01183130
Pescosolido, B. A., Martin, J. K., Long, J. S., Medina, T. R., Phelan, J. C., & Link, B. G. (2010). A
disease like any other? A decade of change in public reactions to schizophrenia, depression, and
alcohol dependence. American Journal of Psychiatry, 167, 13211330. http://dx.doi.org/10.1176/
appi.ajp.2010.09121743
Reivich, K., Gilham, J. E., Chaplin, T. M., & Seligman, M. E. P. (2005). From helplessness to optimism:
The role of resilience in treating and preventing depression in youth. In S. Goldstein & R. B. Brooks
(Eds.), Handbook of resilience in children (pp. 223237). New York, NY: Kluwer Academic/Plenum.
Rosenbaum, T., McMurray, N. E., & Campbell, I. M. (1991). The effects of rational emotive education
on locus of control, rationality and anxiety in primary school children. Australian Journal of
Education, 35, 187200. http://dx.doi.org/10.1177/000494419103500206
Rudish, D., & Millice, N. (1997). From dark to clear thinking: Cognitive restructuring in the classroom.
Reclaiming Children and Youth, 6, 8286.
Schmitt, D. P., & Allik, J. (2005). Simultaneous administration of the rosenberg self-esteem scale
in 53 nations: Exploring the universal and culture-specific features of global self-esteem. Journal
of Personality and Social Psychology, 89, 623642. http://dx.doi.org/10.1037/0022-3514.89.4.623
Seiffge-Krenke, I. (1995). Stress, coping, and relationships in adolescence. Hillsdale, NJ: Erlbaum.
Smith, T. W. (1989). Assessment in rational- emotive therapy: Empirical access to the ABCD model.
In M. E. Bernard & R. DiGiuseppe (Eds.), Inside rational-emotive therapy: A critical appraisal of
the theory and therapy of Albert Ellis (pp. 135153). San Diego, CA: Academic Press.
Snaith, R. P., & Zigmond, A. S. (1986). The Hospital Anxiety and Depression Scale. British Medical
Journal, 292, 344. http://dx.doi.org/10.1136/bmj.292.6516.344
Snyder, C. R. (1994). The psychology of hope: You can get there from here. New York, NY: Free Press.
Snyder, C. R., Ilardi, S., Michael, S. T., & Cheavens, J. (2000). Hope theory: Updating a common
process for psychological change. In C. R. Snyder & R. E. Ingram (Eds.), Handbook of psychological
change: Psychotherapy processes & practices for the 21st century (pp. 128153). New York, NY: Wiley.
Snyder, C. R., Lopez, S. J., Shorey, H. S., Rand, K. L., & Feldman, D. B. (2003). Hope theory,
measurements, and applications to school psychology. School Psychology Quarterly, 18, 122139.
http://dx.doi.org/10.1521/scpq.18.2.122.21854
Spinhoven, P. H., Ormel, J., Sloekers, P. P. A., Kempen, G. I. J. M., Speckens, A. E. M., & Van Hemert,
A. M. (1997). A validation study of the Hospital Anxiety and Depression Scale (HADS) in different
groups of Dutch subjects. Psychological Medicine, 27, 360370.
Strandheim, A., Bjerkeset, O., Gunnell, D., Bjrnelv, S., Holmen, T. L., & Bentzen, N. (2014). Risk
factors for suicidal thoughts in adolescence-a prospective cohort study: The Young-HUNT study.
BMJ open, 4, e005867. http://dx.doi.org/10.1136/bmjopen-2014-005867
Thoits, P. A. (1995). Stress, coping, and social support processes: Where are we? What next? Journal
of Health and Social Behavior, 35, 5379. http://dx.doi.org/10.1186/1471-2458-6-34
Thyer, B. A., Papsdorf, J. D., & Kilgore, S. A. (1983). Relationships between irrational thinking and
psychiatric symptomatology. The Journal of Psychology, 113, 3140. http://dx.doi.org/10.1080/00
223980.1983.9923552
Wahl, A. K., Rustoen, T., Lerdal, A., Hanestad, B. R., Knudsen, Jr., O., & Moum, T. (2004). The
Norwegian version of the Herth Hope Index (HHI-N): A psychometric study. Palliative &
Supportive Care, 2, 255263.
World Health Organization (WHO). (2004). Prevention of mental disorders: Effective interventions
and policy options. Retrieved from http://www.who.int/mental_health/evidence/en/prevention_
of_mental_disorders_sr.pdf
Zachrisson, H. D., Rdje, K., & Mykletun, A. (2006). Utilization of health services in relation to
mental health problems in adolescents: A population based survey. BMC Public Health, 6, 34.
http://dx.doi.org/10.1186/1471-2458-6-34