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¡Descarga RESUMEN DEL CURSO DE PSICOANALISIS y más Resúmenes en PDF de Psicoanálisis solo en Docsity! EMPIRICALLY-BASED CASE STUDIES Using Rational Emotive Behavior Therapy (REBT) with Mixed Martial Arts (MMA) Athletes to Reduce Irrational Beliefs and Increase Unconditional Self-Acceptance Rachel Cunningham1 • Martin J. Turner1  Springer Science+Business Media New York 2016 Abstract The reported application of rational emotive behavior therapy (REBT) with athletes is growing but remains scarce within sport psychology literature. This study used a single-case multiple-baseline across participants design to investigate the effects of REBT on irrational self-depreciation beliefs and unconditional self- acceptance (USA) with three male mixed martial arts (MMA) athletes. Visual and statistical analyses indicate a reduction in total irrationality and self-depreciation and an increase in USA, which was maintained at 6 months post-REBT for two of the three athletes. Social validation data revealed positive changes in emotion management and performance in all athletes. The mechanisms by which REBT promoted changes in self-depreciation and USA are discussed as are recommen- dations regarding the future implementation of REBT with athletes. Keywords Case study  Applied sport psychology  Counseling  Intervention  Combat sports Introduction Developed by Albert Ellis, Rational-Emotive Behavior Therapy (REBT; Ellis 1962, 1984) is an active-directive evidence-based, cognitive behavioral model (David et al. 2010) which helps people deal effectively with distress, achieved by actively– directively disputing irrational beliefs, and then endorsing and maintaining rational beliefs, behaviors, and emotional reactions. According to REBT, there are four core types of irrational beliefs that cause dysfunctional emotions and maladaptive behaviors; demandingness (‘‘I must be accepted’’), awfulizing (‘‘it is awful to fail’’), & Martin J. Turner m.turner@staffs.ac.uk 1 Centre for Sport, Health and Exercise Research, Staffordshire University, Brindley Building, Leek Road, Stoke on Trent ST4 2DF, UK 123 J Rat-Emo Cognitive-Behav Ther DOI 10.1007/s10942-016-0240-4 low-frustration tolerance (LFT; ‘‘I can’t stand unfair treatment’’) and self/other- depreciation (‘‘because I have failed, I am a complete failure’’; Dryden 2009). Also, the fundamental technique of REBT during practice is the disputation of irrational beliefs and endorsement of rational beliefs, thus promoting functional emotions and adaptive behaviors (Ellis and Dryden 1997). Irrational beliefs are associated with dysfunctional emotions such as feelings of anger and shame, and psychopatholog- ical conditions including depression, anxiety, and suicidal thoughts (for a review see Browne et al. 2010), as well as maladaptive behaviors such as social avoidance, self-harming, procrastination, anger suppression, aggression, and violence (for a review see Szentagotai and Jones 2010). In parallel, there are four core rational beliefs; preferences (‘‘I want to be accepted, but don’t have to be’’), anti-awfulizing (‘‘it is bad to fail, but not awful’’), high-frustration tolerance (LFT; ‘‘I can stand unfair treatment’’) and self/other-acceptance (‘‘I am not a complete failure, just because I have failed’’; Dryden 2009). REBT is applicable to athletes who present with irrational beliefs as the main cause of dysfunctional emotions and behaviors and it is possible to assess and target specific core irrational and rational beliefs when working with athletes. The extant literature (see Turner 2014, for review) has reported reductions in athlete irrational beliefs through REBT, but has not yet focused on the disputation of specific irrational beliefs or the promotion of specific rational beliefs. We conducted a needs analysis with three mixed martial arts (MMA) athletes who were the focus of this paper. Our analysis suggested that they would benefit from learning to recognize and dispute self-depreciating beliefs and from learning to adopt a philosophy of unconditional self-acceptance (USA; Ellis 1977). MMA is a full-contact combat sport allowing striking and grappling techniques, both standing and on the ground, from various combat sports and martial arts. MMA is highly physically demanding, with high injury rates (228.7 injuries per 100 fights; Lystad et al. 2014), and fatalities sometimes occur. Indeed, research has found that accepting pain and psychological distress are perceived as part of the training process for MMA athletes (Massey et al. 2013). Due to the high-risk nature of the sport (such as permanent injury or death), individuals have also expressed a shared concern for burning out from training as well as fearing the impact of losing fights on their social identity (Vaccaro et al. 2011). Fear is a fundamental element in the thinking of MMA fighters; two studies (Harpold 2008; Vaccaro et al. 2011) suggest that fear of failure and a focus on creating fear in opponents are the two main concerns expressed by MMA athletes. Both fear avoidance and ego-oriented performance motivations have been linked to negative emotions (e.g., Bartels and Herman 2011) and destructive behaviors such as self-handicapping (e.g., Midgley et al. 1996). Exaggerated fear of events that are not physically dangerous arises from irrational appraisals. Caution for physically dangerous events arises from rational appraisals (Ellis 1985). Vaccaro et al. (2011) identified some of the ways MMA fighters attempt to manage fear, for example by accepting the outcome of any fight as a valuable learning experience, and also pretending that the fight is like a video game thus reducing fear of an opponent. Acceptance is consistent with REBT and is especially evident in the promotion of USA (the A stands for acceptance), but distraction, such as in the video game strategy, suggests that the athletes are R. Cunningham, M. J. Turner 123 Measures Unconditional Self-Acceptance (USA) The Unconditional Self-Acceptance Questionnaire (USAQ; Chamberlain and Haaga 2001) is based on defining self-worth by accepting oneself without the need for approval from others and regardless of personal accomplishments (Ellis 1985). The USAQ consists of 20 items that are measured on a 7-point Likert-scale. Participants are required to rate how often each statement is true about themselves, from 1 (almost always untrue) to 7 (almost always true). Eleven items are reverse-scored, with final scores based on the sum total of all 20 items. The USAQ demonstrated a moderate internal consistency (a = .72) in the original validation study (Chamber- lain and Haaga 2001). Rewording of three problematic items improved internal consistency (a = .86). Research has found inverse relationships between self- acceptance and irrational beliefs (Davies 2008), anxiety (Chamberlain and Haaga 2001) and depressive mood states (Scott 2007). The scale achieved a moderate internal consistency (a = .77) for the current sample. Irrational Beliefs The Shortened General Attitudes Beliefs Scale (SGABS) provides a brief measure of beliefs that has good test–retest reliability (r = .91; Lindner et al. 1999) and good construct, criterion, concurrent, convergent, and discriminant reliability (MacInnes 2003). The SGABS contains 26 statements comprising of 7 sub-scales and assesses both rationality (1 sub-scale) and irrationality (6 sub-scales). An average is calculated for each of the subscales, by dividing the total scores of each subscale by the number of items in the scale (Lindner et al. 1999). Respondents are required to rate their agreement on a 5-point Likert-scale from 1 (strongly disagree) to 5 (strongly agree). A specific focus for this study was the subscale self-depreciation. Total irrationality is computed based on the total sum of the irrationality sub-scales alone with higher scores indicating more irrational beliefs of a greater intensity. Cronbach’s alphas for the current sample ranged between .63–.91 for total irrationality and .72–.93 for self-depreciation. Social Validation There is limited research about athlete and coach assessments of interventions, especially where change in athletic behavior is concerned (Barker et al. 2011). Based on previous research (Page and Thelwell 2013), we conducted semi- structured interviews with the athletes and their coach using a brief, open-ended questionnaire. Basic content analysis was used to identify themes in their responses using guidelines developed by Downe-Wamboldt (1992) and Mellalieu et al. (2009). To assess the stability of athlete and coach beliefs, a brief, client-led discussion was held 2 weeks after the initial brief interview. Using Rational Emotive Behavior Therapy (REBT) with Mixed… 123 Design A single-case, multiple-baseline across participants design was adopted for data collection and analyses of intervention effects (Barker et al. 2013). Past REBT in sport research has also adopted this approach (e.g., Turner and Barker 2013), as it affords an in-depth investigation into a small number of athletes, as would often be the case in applied practice. It was anticipated that a combined quantitative and qualitative analysis would provide further insight into irrational beliefs management in athletes and the practice of REBT with athletes. Three participants are considered an adequate sample size for the implementation of a single-case design (Kazdin 1982). The multiple-baseline-across-participants design is characterized by an A (baseline phase) B (intervention phase) design where the timing of the intervention is staggered across participants. Specifically, participant 1 received the intervention at week 3, participant 2 received the intervention at week 5, and participant 3 received the intervention at week 4. This staggered approach enhances the conviction that observed effects are a function of the intervention rather than extraneous variables (Kazdin 1982). Additionally participants were asked not to discuss the study with each other during baseline to avoid cross-participant contamination. Three baseline data points are recommended as the minimum for single case multiple baseline/across-participants designs (Kazdin 2011). Data Collection Initially, participants completed the SGABS and USAQ as part of the needs analysis. Then, each participant completed the SGABS via an online system developed using the Qualtrics web-based development system, until self-reported irrational beliefs showed a level of consistency (indicating a stable baseline had been achieved; Barker et al. 2011; Kazdin 2011). Participants continued to complete the questionnaire each week throughout baseline and intervention phases. The practitioner contacted each participant on a weekly basis to encourage adherence. The SGABS and USAQ were also administered at a two-week post-intervention follow up to assess whether the intervention effects had been maintained, and at 6 months post-intervention to assess longer-term changes in the targeted variables. To be clear, the USAQ was completed once at each phase (baseline, post- intervention, and 6-month follow-up), while the SGABS was completed weekly throughout all phases, and then once again at the 6-month follow-up phase. Completion of the USAQ was limited to pre, post, and follow-up intervention phases to ensure clients were not overloaded with questions. Further to this, we administered the SGABS weekly because we were more confident in the use of the SGABS for repeated measurement, due to excellent test–retest validity (Cronbach’s a = .91) compared to the USAQ for which there is at present no published test– retest data (Hill et al. 2008). The SGABS has been used more frequently in applied sport psychology research (e.g. Bernard 1985; Elko and Ostrow 1991; Marlow 2009) while this is the first study known to date to apply USA as a specific test of a specific rational belief with athletes. R. Cunningham, M. J. Turner 123 Intervention The REBT intervention included four one-to-one REBT sessions delivered with video calls using the web-based package, Skype, as suggested by Cotterill and Symes (2014). Electronic forms of therapy have previously proven to be effective (e.g., Bewick et al. 2008) with Skype providing the additional benefit of maintaining face-to-face interaction with athletes, who like these athletes, were in distant locations (Bergman et al. 2003). Skype was used instead of face-to-face meetings due to athlete location and availability. The REBT intervention followed recently published guidelines from prominent literature (e.g., David et al. 2010; Dryden and Branch 2008), to ensure consistency in intervention delivery and adherence to the REBT process. To help standardize the REBT intervention across participants and to ensure the REBT ABCDE process was adhered to, each session adhered to a framework that guided the content. The lead practitioner used the ABCDE framework under the guidance of the second author who is also an accredited REBT practitioner in order to ensure the approach was standardized. An initial discussion was conducted with the athlete to discuss performance concerns and to explore their irrational beliefs. Participants were asked to keep a diary of their thoughts in and/or relating to their training and competition, including thoughts they could recall from training and competition episodes. Their diaries further confirmed the athletes’ self-depreciation beliefs, particularly around ‘being good enough’ for participant 1 and 2, and regarding attention to failure in participant 3. The subsequent sessions implemented the REBT ABCDE process. Athletes were encouraged to understand that their beliefs (B) cause emotional and behavioral consequences (C) not activating events (A) alone, and that they can dispute (D) their irrational beliefs to promote more functional emotional and behavioral effects (E). The intervention started with a training (or psychoeducational) phase during the first meeting in which the athlete learned about the ABCDE process. Once this concept was fully understood the athlete identified the A in the second session, discussed the related irrational beliefs (B) and how these were linked with unhealthy emotions/ behaviors (C) normally in the third session. Beliefs relating to self-depreciation were disputed (D) and rational beliefs generated in collaboration with the practitioner in the concluding session. During the disputation phase the practitioner worked with the athletes to establish greater acceptance through less rigid self- appraisal. The athlete’s social context was also explored to identify other potential triggers of self-depreciation and to enhance adaptability in the presence of adversity. Homework assignments were administered after each meeting. These consisted of practical tasks and self-help worksheets based on the proceeding session. Finally the last session focused on reinforcing independent use of the ABCDE process, and provided a review of the coping strategies the athlete had developed during REBT. For clarity, examples of this process for each individual are described in the following passages. Using Rational Emotive Behavior Therapy (REBT) with Mixed… 123 (Ottenbacher 1986), based on the recommendations of Parsonson and Baer (1978, in Barker et al. 2013). Briefly, intervention effects were compared to stable baseline levels, with immediacy of change and low number of overlapping data points considered preferable, and the consideration of the overall pattern of change. Data for SGABS subscales were plotted for each participant to assess changes across time points. For brevity and because of the intervention focus, graphs were plotted for total irrationality (Fig. 1) and self-depreciation (Fig. 2) only. Statistical Analysis Intervention effects were assessed as recommended for use in single-case designs (Barker et al. 2013). Effect Size (ES) was calculated using Cohen’s d. where M1 - M2 provides the difference between the mean pre- and post-test scores. SD1 refers to the mean standard deviation of pre-intervention scores and SD2 is the mean standard deviation of post-intervention scores: Cohen’s d ¼ Cohen’s d ¼ M1 M2=SDpooled ðwhere SDpooled ¼ pðSD2 1 þ SD2 2Þ=2Þ Cohen (1992) suggested specific categories for effect size interpretation with .2 as small, .5 as medium and .8 as large, although this originates from group research. In an assessment of single-case AB designs Parker and Vannest (2009) determined that\.87 indicated a small effect while .87–2.67 suggested a medium effect and a large effect being anything[2.67. Therefore the latter was selected for this analysis because single-cases (athletes) were assessed. To determine whether the magnitude of change for each participant was also statistically reliable, the present analysis included calculating the Reliable Change Index (RCI; Jacobson and Truax 1991) for total irrationality, self-depreciation and USA. The RCI is the difference between the participants’ pre- and post-test scores divided by the Standard Error of the Difference (SED; Jacobson and Truax 1991). If the value of the RCI greater than 1.96, then the probability that the change in score is random is less than .05. RCI values are provided for each individual on total irrationality, self-depreciation, and USA in Table 1. Total Irrationality Overall there was a significant, t (2) = 3.25, p = .05, reduction in total irrationality across participants from pre- (M = 3.65, SD = .61) to post-intervention (M = 3.28, SD = .61). According to Lindner et al. (1999) scores above 2.37 indicate that total irrationality is above the population mean. Therefore the intervention appeared to reduce total irrationality below this level for Participant 2 only. Participant 1 was already below this threshold and although Participant 3’s total irrationality score decreased, it remained high relative to the population mean. Participant 1 showed a small decrease (d = .17) in total irrationality from pre- (M = 3.19, SD = .06) to post-intervention (M = 3.08, SD = .06), where response scores initially decreased from the baseline phase with the lowest score immediately R. Cunningham, M. J. Turner 123 4.50 4.45 4.64 4.55 4.45 4.36 4.45 3.86 3.68 3.82 3.36 2.00 2.50 3.00 3.50 4.00 4.50 5.00 Participant 3 3.23 3.14 3.00 3.09 3.14 2.00 2.50 3.00 3.50 4.00 4.50 5.00 Participant 1 3.55 3.41 3.64 3.50 3.50 3.05 2.45 2.41 2.14 2.00 2.50 3.00 3.50 4.00 4.50 5.00 Participant 2 To ta l I rr at io na l B el ie fs Fig. 1 Total irrational beliefs scores across intervention phases for all participants Using Rational Emotive Behavior Therapy (REBT) with Mixed… 123 1.75 2 2 2 2 0 0.5 1 1.5 2 2.5 3 3.5 4 Participant 1 2 2 2.25 2 2.25 2 1 1 1 0 0.5 1 1.5 2 2.5 3 3.5 4 Participant 2 4 4 4 4 4 3.75 4 3 2.5 2.75 2.25 1 1.5 2 2.5 3 3.5 4 4.5 5 Participant 3 Se lf- D ep re ci at io n Fig. 2 Self-depreciation scores across intervention phases for all participants R. Cunningham, M. J. Turner 123 his new rational beliefs (E), demonstrating a healthier approach to his diet plan. He stated, ‘‘Break it down, make a plan… see if I can change things, and if I can’t, let it go…’’ The coach confirmed the presence of increased sense of control amongst athletes. ‘‘He’s [participant 3] just doing what he needs to do…focused on the task’’ Reflection All participants recognized their old behaviors in other fighters within the gym, and commented on witnessing others go through similar anxieties such as ‘‘energy wasting’’ worries in the pre-fight process. Participants 1 and 3 particularly commented on their ability to question themselves when they experienced dissatisfaction with performance. They used this self-assessment to improve performance and accept losses as part of the process of becoming an elite athlete. Participant 1 described his new experience on fight day, ‘‘As far as I’m concerned, it’s an opportunity… I watched the guys sitting there, seeing them look worried and thought that’s how I used to be… Now I take myself to a quiet spot, focus my thoughts’’ Decrease in Unhealthy Thoughts/Emotions Participant 1 reported feeling that he was able to accept change and he had less debilitating emotional responses. Participant 2 reported being able to remain motivated when he was training. This athlete also indicated the impact the REBT had on all aspects of his life, including reduced anxiety in making career decisions he had been putting off for some time. The coach believed the athletes were less worked up about getting things right and instead were able to focus on improving. Perception of Enhanced Athletic Performance Participant 1 spoke of ‘‘good days and bad days’’ in training but in his last win demonstrated the ability to make his opponent ‘‘fight my [his] fight’’. He explained this as using his strengths to capitalize on his opponent’s weaknesses. Participant 3 was able to recognize where he was in his long-term plan to becoming an elite athlete. He was able to recognize his current skills instead of continual striving to be as good as those at the ‘‘top of their game’’ which previously lead to procrastination and disappointment in the self. The coach also recognized that these athletes sought less confirmation of good performance from him, and although participant 3 still wanted to gain his respect, checking to see whether he had done something right or wrong had become less frequent. Discussion The purpose of this study was to examine the effects of REBT, on self-depreciation and USA in MMA athletes. This is the first study to focus on self-depreciation and USA in an athlete population, and the first to apply REBT with MMA athletes. Using Rational Emotive Behavior Therapy (REBT) with Mixed… 123 Based on visual and statistical analyses the results indicate that for two participants the intervention was able to reduce self-depreciation and increase USA as hypothesized. Participant 1’s irrational beliefs scores showed only marginal change at the end of the intervention, and he did not complete the follow-up inventories. However, participant 1 expressed greater acceptance of failure in the social validation data. While it is theoretically plausible that self-depreciation and USA are negatively related, this may not be the case for all people. In participants 2 and 3, self-depreciation decreased from baseline and remained reduced at the 6-month follow-up phase. This finding supports the vast literature advocating the use of REBT to reduce irrational beliefs (e.g., see David et al. 2005 for a full synopsis), and specifically within the domain of sport psychology (e.g., Larner 2008; Turner and Barker 2013). Social validation confirmed the reduction of self-depreciation and increase in USA, alongside various positive effects of the intervention such as enhanced emotional control and performance. However it is important to note that although effect sizes calculated using Cohen’s d (Cohen 1992) indicated small to medium changes from pre- to post-REBT, RCIs did not meet the criteria set by Jacobson and Truax (1991) to indicate significant intervention effects. This is the first study to focus on the self-depreciation beliefs of athletes and the impact of REBT on reducing self-depreciation beliefs. Rather than reacting to failure with ‘‘I am a failure’’ beliefs, athletes instead react with ‘‘I may have failed but that does not mean I am a failure’’ beliefs. Adopting low self-depreciation beliefs can help athletes to react to adversity with functional emotions and behaviors such as sadness and acute withdrawal, rather than dysfunctional emotions and behaviors such as depression and chronic withdrawal (e.g., David et al. 2002; Szentagotai and Jones 2010). This may be of particular salience to MMA athletes where a culture of fear not only exists, but is often promoted (Harpold 2008; Vaccaro et al. 2011). The findings of this study may help to develop effective strategies for managing fear in MMA athletes, although more research is required. Notably, USA increased in all three participants, even in participant 1 who showed a small and unstable increase in self-depreciation. The increases in USA in participants 2 and 3 could be related to the decreases in self-depreciation, but for participant 1 it may be that his self-depreciation beliefs were unrelated to his USA beliefs. In REBT it is possible to harbor both irrational and rational beliefs (e.g., Ellis and Dryden 1997). Therefore, just because participant 1 did not hold high self- depreciation beliefs at baseline, it does not mean that he held high USA beliefs. For participant 3, RCIs for USA did indicate reliable change and therefore suggest that the inclusion of this measure with MMA athletes could be a useful indicator of whether an intervention decreased irrational, and increased rational beliefs. It may be that the discrepancy in RCIs between the SGABS scores and USAQ scores indicates the use of the SGABS with this population needs to be refined in future research. In contrast to self-depreciation, USA reflects unconditional regard for oneself despite undesirable behavior and adverse events. Previous research outside of the sport psychology literature has found that self-depreciation involves intensive self- evaluation, which opposes USA. This can lead to negative emotions such as depression (Scott 2007) and thought consequences such as self-blame and self- R. Cunningham, M. J. Turner 123 criticism (Hill et al. 2008) and may increase the propensity for narcissism, self- centeredness and downward social comparison (Neff 2003). Therefore, it is perhaps unsurprising that with reductions in self-depreciation beliefs found in this study, increases in USA were also evident. It should also be noted that while reducing self-depreciation to augment USA was the specific focus of the REBT intervention with the athletes, changes in total irrationality were also detected. Participant 2 and 3 both showed a meaningful decrease in total irrationality, which is a composite of various types of irrational beliefs described in REBT theory. The finding that other irrational beliefs can be reduced by focusing on very specific irrational beliefs (such as self-depreciation) is consistent with past research in sport (e.g., Turner and Barker 2014) and may suggest that irrational beliefs are interconnected. For example, the reduction in self- depreciation beliefs may also reduce need for achievement, because the demand for success may be negated by the increased acceptance of failure. In addition, a reduction in self-depreciation beliefs may also lead to reduced need for achievement beliefs if at an individual level, demandingness is less prevalent in some athletes. This interconnectedness is referred to as the ‘‘spillover effect’’ at the beliefs level in that point, and is mentioned extensively in the REBT literature (e.g. David et al. 2010). Again, for participant 1 the reduction in total irrationality was very small despite increases in USA. This may further support the notion that irrational beliefs are not necessarily related to rational beliefs and therefore may be relatively orthogonal (i.e., they do not correlate highly; Ellis et al. 2010). The use of a single-case design in this paper allowed for idiosyncratic observations of each participant before, during, and after the REBT intervention and via social validation. For example, although Participant 1 did not demonstrate quantitative reductions in irrational beliefs, he expressed being able to now accept his weaknesses, recognize his strength, and focus on becoming a professional fighter. Indeed, an awareness of personal failures is considered part of the process of moving from unhealthy to healthy self-appraisal (Driscoll 1989; Dryden and Neenan 2004). Participant 2 reported a high estimation of his performance, along with reduced anxiety (in sport and in life), which has previously been associated with engaging in self-blame and selective attention to failures (Dunn et al. 2006). Participant 3 gained a new understanding that his peers and significant others would not be disappointed in him should he lose a fight. This irrational fear was originally holding him back from entering a competition, and it appeared he no longer believed that being a successful athlete required winning every fight. By challenging the cognitive evaluation of an event and not the event per se, or the emotional outcome, participant 3 was able to accept his failings as part of the process of becoming an elite MMA fighter. Appropriate evaluation of practice is considered a key issue in applied sport psychology literature (Grove et al. 1999; Strean and Roberts 1992). 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