The Effectiveness of Rational-Emotive Therapy in the Reduction of ...

Journal of Cognitive Psychotherapy: An International Quarterly, Volume 5, Number 2,1991

The Effectiveness of Rational-Emotive Therapy in the Reduction of Muscle Contraction Headaches Thomas Finn Hofstra University Raymond DiGiuseppe St. John's University and Institute for Rational-Emotive Therapy Clayton Culver New School for Social Research The study tested the effectiveness of RET in treating muscle contraction headaches. Thirty-five adult subjects diagnosed as muscle contraction headache sufferers completed one of four treatment conditions: Rational-Emotive Therapy (RET); Progressive muscle relaxation (PMR); Headache discussion (HAD), which discussed historical roots of symptoms and monitored cognitive responses but learned no specific coping techniques; and a Waiting list symptom monitoring group (WLC). Dependent measures consisted of data on each subject's weekly headache duration, frequency, severity, and number of headache-free days. These measures were derived from a daily headache diary. Frontalis EMG was also measured. After a treatment program of 10 weekly one-and-one-half-hour group therapy sessions, both the RET and PMR groups had significantly lower headache severity scores, headache frequency, than the HAD and WLC groups. While changes in headach duration and headache-free days were not significant, patterns of these means were consistent with the other measures showing a decrease in headache pathology. At follow-up, ratings of headache improvement done by each subject and by a significant other showed the RET group reported greater improvement than the PMR and HAD groups, which did not differ. The results suggest that RET and PMR were equally effective in the treatment of muscle contraction headaches.

An increasing number of studies have assessed the efficacy of psychological treatments in reducing pain. Many techniques are now viewed as useful in the © 1991 Springer Publishing Company

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management of pain, particularly in the treatment of muscle contraction headaches (Holyroyd et al., 1984). This type of headache, commonly referred to as a tension headache, is characterized by dull, steady pain which lasts for hours or days and is experienced by many patients as a tight band of constriction or pressure. Psychological factors, such as anxiety or tension, which lead to sustained muscle contractions in the head, neck, and shoulders are frequently described as major precipitators of muscle contraction headache pain (Bakal, 1975). Muscle contraction headaches have been successfully treated via relaxation and biofeedback, with both techniques showing equal effectiveness (Blanchard, Andrasik, Ahles, Teders, & O'Keefe, 1980). These authors suggest that there is little need to continue direct comparison of relaxation to biofeedback techniques, although it may prove valuable to compare these established treatments to newer methods. In addition, more cognitively oriented strategies which address the role of maladaptive cognitions in emotional distress have been utilized in the treatment of muscle contraction headaches. Holyroyd, Andrasik, and Westbrook (1977), for example, compared a cognitive treatment to standard EMG biofeedback and found that only the cognitive therapy group had significantly reduced the severity and frequency of headache symptoms. In a second study Holyroyd and Andrasik (1978) compared a cognitive self-control group to a combined cognitive and relaxation group in which subjects were not taught specific responses to stress but discussed the historical roots of their symptoms. Results showed that all groups improved relative to a symptom-monitoring control condition. The authors suggested that while the cognitive treatment for muscle contraction headaches is effective, training in specific coping strategies may not be necessary since the discussion group members seemed to devise their own coping strategies. Holyroyd and Andrasik (1978) appeared to use a combination of many cognitive techniques (e.g., those of Beck and Meichenbaum). Therefore, their study was not a test of any one cognitive technique. Rational-Emotive Therapy (RET) has received some support in reducing self reports of anxiety (DiGiuseppe, Miller, & Trexler, 1977; Haaga & Davison, 1989; Lipsky, Kassinove, & Milier, 1980), but so far no studies have appeared that test its effectiveness in treating psychophysiological disorders. A goal of RET is lowering anxiety and arousal. It is hypothesized that restructuring a client's thinking about life events (Walen, DiGiuseppe, & Wessler, 1980) should prove to be an effective method of decreasing anxiety in muscle contraction headache clients. If anxiety is an etiological factor in muscle contraction headaches, and if irrational beliefs lead to anxiety, a decrease in anxiety should be followed by a corresponding decrease in headache symptoms. The present study assessed the effectiveness of RET in reducing muscle contraction headache symptoms. RET is often considered a combination of many cognitive and behavioral techniques. However, Ellis (1979) has noted that the term RET has a general and a more classical meaning. General RET refers to the psychotherapeutic practice of all cognitive-behavioral techniques, whereas classical RET refers to the logical

RET and Tension Headache

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disputing of evaluative cognitions or irrational beliefs and not to empirical disputing of automatic thoughts (Ellis, 1977,1980; Ellis & Dryden, 1987). The present study differs from Holyroyd, Andrasik, and Westbrook (1977) and Holyroyd and Andrasik (1978) in that these two studies test a combination of cognitive strategies while the present study tests one cognitive strategy, classical RET. It is important to test the efficacy of RET with tension headache, since Ellis (Ellis & Bernard, 1985) has proposed RET as a general treatment for stress-related disorders. In order for RET to be useful and cost effective as an alternative treatment it would have to compare favorably with the most effective treatment available. Following the recommendation of Blanchard et al. (1980), RET was compared to progressive relaxation. A nonspecific treatment group patterned after the headache discussion group of Holyroyd and Andrasik (1978) was also included to partially replicate this previous study and to further explore the value of teaching specific strategies for coping with stress. A symptom-monitoring group was included as a control condition. An attempt was also made to partially replicate Blanchard, Andrasik, Neff, Jurish, and O'Keefe's (1981) procedure for socially validating change in headache symptoms in which a significant other of each subject rated his/her perception of the subject's overall headache change. This was considered important in validating the subject's self-report of improvement.

METHOD Subjects Subjects were recruited by radio, newspaper, and television announcements. These announcements offered treatment services for muscle contraction headache symptoms as a part of a research program. Characteristics of the 35 participants as assessed at screening interview were as follows. Total headache duration ranged from 6 months to 40 years, with a mean duration of 11.76 years. There were 12 men and 23 women. The mean age was 32.94 years, ranging from 20 to 61. Twenty-eight subjects were employed, five of which were housewives. One was unemployed, and one was a full-time college student.

Procedure Subjects were instructed to contact the experimenters to set up a screening interview. At this telephone interview a symptom checklist was administered. Subjects who met the criteria of the checklist were mailed a Physician's Headache Diagnosis form which was to be completed prior to admission to the study. Only those subjects who were classified by their physician as muscle contraction

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headache sufferers were permitted to continue in the screening process. Subjects who passed these two screening phases were then seen in a diagnostic interview in which a more detailed symptom history was obtained. If the more detailed history led to disagreement with the physician's diagnosis, the subject was dropped from the study. Subjects took the MMPI (Hathaway & McKinley, 1967). Subjects who scored above 70 on the paranoia scale were excluded. All subjects who were excluded were given appropriate treatment referral. Recordings of the resting frontalis electromyograph EMG were then obtained as follows. Subjects were seated in a comfortable chair and surface electrodes connected to a Cyborg EMG and integrator were placed on the subjects' frontalis muscle. Subjects were told to make themselves comfortable and relax, using any means they could. EMG recordings were taken at 1 minute intervals for 30 minutes. The 30 measures were averaged to form one score per subject. Lower scores reflect greater relaxation. The procedure was repeated at post-test. Following the screening, subjects were randomly assigned to one of the three treatment conditions or the control group. Two therapists each led one group in each treatment condition with a maximum of six subjects per group. All therapists were fourth year graduate students in clinical psychology who had completed an internship. The treatments consisted of 10 weekly one-and-one-half-hour group sessions. Subjects met in their assigned groups for an initial session, where they were instructed in the use of a headache activity measure. Subjects rated each of their headaches on a 1 to 5 Likert scale of severity and marked the onset and termination of each headache on the headache data sheet. From this form measures of headache severity, duration, frequency and headache-free days were obtained. The subjects in the RET, PMP, HAD groups were told to record their headache activity daily for the next two weeks. Any headache that occurred between 6:00 AM and 12:00 PM was recorded. These data served as the subject's baseline data. Any day for which no headache was recorded counted as a headache-free day. Waiting list/symptom monitoring subjects were informed that they would begin treatment as soon as their monitoring period was over. They were also instructed to record their headache activity daily and told that an experimenter would contact them periodically by telephone. This was done to maintain contact with the subjects. Thirty-five subjects completed the program. There were 8 subjects in the progressive muscle relaxation (PMR) and the Rational-Emotive Therapy (RET) groups, 9 in the waiting list control (WLC), and 10 in the headache discussion (HAD). Four subjects dropped out from each of the PMR and RET groups, two from HAD, and three from the WLC. At the conclusion of the 10-week treatment period subjects met for posttesting. At this time they filled out post-treatment questionnaires, and EMG was assessed. As part of the post test, subjects rated their change in headaches and each subject selected a significant other to rate the subject's headache change. The self-


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and other ratings were on a scale of -100 to +100. A score greater than zero represented improvement. Zero indicated no change, and less than zero indicated exacerbation. Two months after the end of treatment follow-up, measures were taken from treatment group subjects. Subjects recorded their headache activity for one week.

Rational Emotive Therapy Subjects in the RET treatment were taught the basic ABCs of RET of Ellis (1962). They were taught to monitor their thoughts during periods of emotional upset. They were specifically taught to look for irrational beliefs such as absolutistic demanding statements ("Musts"), Awfulizing/Catastrophizing statements, and self-denigrating statements. They were taught to dispute these beliefs and replace them with alternative rational thoughts. The sessions included rational emotive imagery, rational role reversal and the use of rational self-help homework sheets. The homework sheets were reviewed in each session. The therapists had read an RET treatment manual (Walen, DiGiuseppe, and Wessler, 1980) and attended an intensive five-day training program in RET. They were also required to present four tapes to the second author, demonstrating competency in "Classical RET" before the study commenced.

Relaxation Treatment Subjects in the relaxation condition were provided a rationale, emphasizing that muscle contraction headaches result from stress. A decrease in muscle tension due to relaxation should bring about a corresponding decrease in headache. Relaxation training followed the procedures described in Bernstein and Borkovec (1973). Subjects were instructed to practice relaxation at home, twice daily, for 15 to 20 minutes.

Headache Discussion The headache discussion condition was patterned after Holyroyd and Andrasik's (1978) headache discussion group. Subjects were presented with the rationale that their headaches were a result of psychological stress. They were told that their stress would decrease if they understood the root of their problems. Subjects were encouraged to examine the cognitions and emotions that coincided with their headaches for clues that might provide insight into the underlying source of their stress. The therapists were to provide an explanation of the subjects' distress based on historical life events (e.g., "Your anxiety appears to be a natural response to the way you were treated as a child."). Subjects were encouraged to discuss their emotions regarding stressful life events. The therapist attempted to emphasize similar difficulties and responses and offered interpretations that linked past

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life events with present emotions and behaviors. At no time did the therapist suggest specific methods for coping with stress and was sure to prevent other members from offering this type of advice. In order to make the headache discussion condition as similar as possible to the RET and relaxation conditions, an attempt was made to match as many active treatment components as possible. Imagery exercises and homework assignments were included in the headache discussion condition. At certain points in treatment headache discussion subjects imagined stressful events from their past and present and then described their subjective experiences. Subjects were given weekly homework assignments which required them to relate their response to any stressful event that appeared related to their past (e.g., "I used to respond that way to my mother."). Role-playing was also used during each session. Members of the waiting list/symptom monitoring group were informed that they had been placed on the program's waiting list. Their only contact with an experimenter was at pre- and post-test sessions and telephone conversations during the data collection period. Subjects were encouraged to continue recording their headache activity at the end of these telephone conversations. They began treatment at the earliest possible time following the recording period. Manipulation check. In order to ascertain that the therapists were actually complying with the treatments every session was recorded. The therapists were told that session tapes would be chosen at random and reviewed for compliance by the second author. Three session tapes for the RET, PMR, and HAD were reviewed and found to follow the Treatment Plan. Dependent measures. From the data recording log that was described, measures of headache frequency, headache duration, headache severity and headache-free days were calculated, a description of each follows: Headache frequency data were obtained from each client's headache data sheet and consisted of the number of headaches a subject reported each week. A headache was considered to have occurred when its onset and termination was clearly specified by a subject on the data sheet. Frequency was added across the last week of baseline to form the pre-test score and added across the last week of treatment to form the post-test score. The follow-up sum was based on data collected in one week. Headache duration was obtained from the headache data sheet and consisted of the number of hours per week a subject reported having headache pain. Number of hours was counted daily from headache onset to termination, and total number of daily hours was summed across seven days to obtain the weekly headache duration figure for pre-test, post-test and follow-up. Headache severity consisted of mean weekly intensity ratings. Subjects rated each headache on a one to five scale. In the event a change in intensity occurred during the day and a headache thereby received more than one severity rating, the highest rating was used in the average.

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The measure of headache-free days consisted of the number of days per week during which no recording of headache activity appeared on a subject's headache data sheet. Frontalis muscle EMG was used as a dependent measure, using a Cyborg model P303 and a 700 integrator at both pre- and post-treatment. The method of taking the recordings was described above. The data were averaged to form one score per subject for pre-test and again at post-test. Three other dependent measures were obtained at follow-up in an attempt to look at social validation of headache behavior. This included Likert ratings of TABLE 1. Means & Standard Deviations for all Dependent Measures at Pre & Post Test Dependent Variable Dependent Variable: Dependent Variable: Headache Free Days Headache Duration Headache Severity Pre

Post

Pre

Post

Pre

Post

( -75) 2.81 ( -71) 3.44 ( -73) 2.17 (. 66)

1.80

2.10 ( -72) 5.25 ( -82) 5.00 ( -89) 2.22 ( -86)

59.43 (14.07) 39.91 ( 8.61) 31.66 (12.44) 39.69 (12.60)

67.40 (16.13) 17.50 (13.42) 23.25 (14.14) 43.67 (13.89)

2.27 ( .28) 2.72 ( .31) 2.36 ( .19) 2.79 ( .25)

2.71 ( .20) 1.35 ( .45) 1.24 ( .40) 2.68 ( .26)

2.50 ( -34) 35

3.51 ( -47) 35

43.54 ( 6.21) 35

39.80 ( 7.81) 35

2.53 ( .13) 35

2.05 ( .20) 35

Dependent Headache Pre

Variable EMG Post

Group HAD RET PMR WLC

Total:

Dependent Variable Headache Frequency Pre Post

Group HAD RET PMR WLC

5.80 ( -81) 5.25 ( -98) 4.25 ( -85) 6.94 (2.25)

4.90 ( -72) 1.75 ( -82) 2.00 ( -89) 6.44 (1.93)

3.38 ( .25) 4.34 ( .75) 4.32 (1.65) 3.24 ( .97)

3.63 ( .42) 3.91 ( .43) 2.62 ( -30) 3.53 (1.19)

5.61 ( -68)

3.91 ( .67)

3.79 ( .47)

3.44 ( .33)

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improvement by the therapist and the client, and a significant other rating of the clients' headache behavior.

RESULTS A total of 10 F tests were completed, 5 one-way covariance analyses on the posttest (one for each measure) and 5 on the follow-up data. To control for the experimentwise inflation of the error rate an alpha level of .025 was set for all significance tests. All post hoc tests were performed using Fisher's LSD method. The data were analyzed by analyses of covariance with four levels of treatment and with the pre-test score used as the covariate for each analysis. EMG was not significant. This result is not surprising as the literature has shown that reduction in frontalis tension is not necessary for a reduction in headache pain (Holyroyd et al, 1984). Headache duration also was not significant, but did approach significance; F(3,30) = 2.634, p < .068. Severity was significant; F(3,30) - 6.179) p < .0021. The main effects for headache-free days also approached significance; F(3,31) = 3.341,/? < .032. The main effect for headache frequencies was significant; F(3,3O) = 4.119,/? < .015. Post hoc tests done on severity and frequency data were only partially consistent with our hypotheses. The RET and PMR groups scored lower on severity and frequency than the HAD and WLC groups. While RET and PMR were more effective treatments than HAD and WLC, RET was not different from PMR. This pattern suggests that RET and PMR are equally effective in the treatment of muscle tension headaches. The RET and PMR groups showed trends of improvement on all dependent measures except for EMG. In contrast, the HAD group showed slight (but not significant) improvement on headache frequency and EMG, the WLC group showed slight (but not significant) improvement on headache severity, frequency and the EMG. At the follow-up two months later all subjects in the WLC group had dropped out of the study. Consequently, we analyzed the follow-up data separately, using one-way ANCOVAs with three levels of treatment for headache duration, headache severity, headache frequency, headache-free days, again with pre-test scores as the covariat, with resulting loss of power. At follow-up, headache duration, severity, frequency, and headache-free days did not reach significance. However, patterns of descriptive statistics were the same at follow-up as at post test. Means of RET and PMR groups were close to each other, and both of these groups were approximately one-half as pathological as the HAD group. Table 2 contains means for follow-up data. Examination of the raw data is striking. The medians of the RET and PMR groups are always very close and the first three quartiles of the HAD group invariably fall on the more pathological side of these medians. This pattern will be discussed below.


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TABLE 2. Means, Standard Errors (SE), and n's for Main Effects, Marginals, and Two Factor Interaction, within Cell Dependent Measure Other Headache Headache Headache Headache Therapist Self Duration Severity Frequency Free Days Rating Rating Rating Group: HAD RET PMR

Total:

58.50 (18.11) 24.75 (14.14) 28.19 (14.57)

2.51 ( .26) 1.66 ( .53) 1.57 ( .43)

4.67 ( .94) 2.13 ( .88) 2.38 ( .94)

2.44 ( .91) 5.00 ( .85) 4.63 ( .94)

10.20 ( .51) 11.29 ( .58) 10.25 ( .56)

59.90 61.00 ( 3.59) ( 4.02) 87.86 85.86 ( 3.19) ( 4.99) 72.88 76.71 ( 8.37) ( 4.57)

38.00 ( 9.21)

1.94 ( -24)

3.12 ( -53)

3.96 ( .52)

10.55 ( -32)

71.88 72.83 ( 3.16) ( 2.59)

One-way ANOVAs using a three-level treatment group factor were performed on follow-up measures of therapist rating of improvement, self-rating of improvement, and significant other rating of headache behavior. Therapist rating was not significant. The group effect on self-rating was significant, F(2,22) = 6.455, p < .006, and the same effect was noted for the significant other rating; F(2,21) = 8.385,/? < .002. Post hoc tests performed on the significant effects demonstrated that the RET group was rated significantly higher on improvement on the clients' ratings and the significant others' rating of headache behavior than the HAD group. There was no significant difference between the PMR group and the RET group or the PMR and the HAD groups.

DISCUSSION The result of this study indicated that progressive muscle relaxation and rationalemotive therapy are useful strategies in reducing the frequency and severity of muscle contraction headaches. No significant improvement was found on measures of headache duration, headache-free days and EMG. For the measures of headache duration and headache-free days the results approached significance and were similar in direction to the measures of headache frequency and severity. It is believed the data for headache duration and headache-free days would have been significant if statistical power were increased by increasing the number of subjects. At follow-up, measures of headache severity, duration, frequency and headache free days did not reach significance; however, patterns of descriptive statistics were the same as the measures at post-test. We suggest a lack of power accounted for the failure to attain significance at follow-up. The results of the social validation measures at follow-up are suggestive of maintenance. For the

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follow-up, the therapists' and clients' ratings of improvement, and the significant others' ratings of clients' headache behavior indicated that for all three measures the means for the RET and PMR group remained close to each other, and showed consistently lower headache pathology than the HAD group. It is noteworthy that only measures where a pre-test assessment did not occur were significant at follow-up. These significant follow-up results therefore could be an artifact of initial differences. Inspection of quartiles at two-month follow-up, however, further supported the consistency of results at post-test. There are three points that we want to stress here. The first is that the pattern of results was consistent from post-test to follow-up. RET and PMR groups tended to do better than HAD. The second is that our small sample sizes reduced the power of the tests used. Had sample sizes been larger we expect that the reported trend for the group main effect on duration data would have been significant, and we expect that all improvements would have been maintained at follow-up. The third is that there is some consensus in the literature that PMR is an effective treatment for tension headaches (Blanchard et al., 1980), and the present data suggest that results for RET are at least comparable to those for PMR. The ability of RET to affect improvements similar to relaxation, as found in the present study, suggests that RET may also be useful in the treatment of muscle contraction headaches. Blanchard et al. (1980) explained equivalent results for relaxation and biofeedback in reducing headache symptoms by stating that results may have been due to a common pathway, namely, relaxation. It may also be the case that a common pathway is at work with cognitive-behavioral interventions such as RET, perhaps anxiety reduction. Future research needs to focus on this common pathway and how it would be involved in cognitive-behavioral treatment of muscle tension headaches. Given the present results, it would appear worthwhile to continue testing the effectiveness of RET and other cognitive-behavioral strategies in reducing headache symptoms. It may also be true that subgroups exist that will differentially benefit from different forms of treatment. Some types of individuals may benefit more from PMR and others may do better from a cognitive-behavioral technique such as RET. The existence of subgroups is another issue that needs to be explored in future research. Some headache sufferers may prefer active approaches, other passive medical approaches. This may account for the different drop-out rates: four subjects dropped out of the RET and four from the PMR group; two from the HAD; and one from the WLC. While these differences do not appear large, slightly more subjects dropped out of the treatment than the control groups. This may have occurred because both treatment groups require active participation. It is possible that headache clients are more likely to drop out when they are required to actively engage in the treatment. In summary, the present study compared the efficacy of RET to progressive muscle relaxation in the treatment of muscle tension headaches. Results supported the hypothesis that RET and progressive muscle relaxation are both effective in


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temporarily modifying treatments for tension headaches and are suggestive of some possible maintenance effect. Suggestions were made for future research on cognitive-behavioral interventions in the treatment of muscle contraction headaches.

REFERENCES Bakal, D. K. (1975). Headache: A biopsychological perspective. Psychological Bulletin, 8, 369-382. Bernstein, D. A & Borkovec, T. (1973). Progressive Relaxation Training: A Manual for the Helping Professions. Champaign, IL: Research Press. Blanchard, E., Andrasik, F., Ahles, T., Teders, S., & O'Keefe, D. (1980). Migraine and tension headache: A meta-analytic review. Behavior Therapy, 11, 613-631. Blanchard, E., Andrasik, F., Neff, D., Jurish, S., & O'Keefe, D. (1981). Social validation of the headache diary. Behavior Therapy, 12, 711-715. DiGiuseppe, R., Miller, N., & Trexler, L. (1977). A review of rational emotive therapy, outcome studies. The Counseling Psychologist, 7, 64-72.. Ellis, A. (1977). Rational-emotive therapy: Research data that supports RET and other modes of cognitive-behavior therapy. The Counseling Psychologist, 7, 2-41. Ellis, A. (1979). Theoretical and empirical foundations of rational-emotive therapy. Monterey, CA: Brooks/Cole. Ellis, A. (1980). Rational-emotive therapy and cognitive behavior therapy: Similarities and differences. Cognitive Therapy and Research, 4, 325-340. Ellis, A., & Bernard, M. (1985) (Eds.). Clinical applications of rational-emotive therapy. New York: Plenum. Ellis, A., & Dryden, W. (1987). The Practice of rational-emotive therapy. New York: Springer Publishing Co. Haaga, D., & Davison, C. (1989). Outcome research in RET. In M. Bernard and R. DiGiuseppe (Eds.), Inside RET: A critical appraisal of the theory and therapy of Albert Ellis. New York: Academic Press. Hall, J., & Chila, A. (1984). Change mechanisms in EMG biofeedback training: Cognitive changes underlying improvements in tension headache. Journal of Consulting and Clinical Psychology, 52, 1039-1053. Hathaway, S. R., & McKinley, S. C. (1967). Manual for the Minnesota Multiphasic Personality Inventory. New York: The Psuchological Corporation. Holyroyd, K., & Andrasik, R. (1978). Coping and the self-control of chronic tension headache. Journal of Consulting and Clinical Psychology, 46, 1036-1045. Holyroyd K., Andrasik, F. & Westbrook, R. (1977). Cognitive control of tension headache. Cognitive Therapy and Research, 1, 121-123. Holyroyd, K., Penzien, D., Hursey, K., Tobin, D., Rogers, L., Holm. J., Marcille, P., Lipsky, M., Kassinove, H., & Miller, N. (1980). Effects of rational-emotive therapy, rational role reversal, and rational-emotive imagery on the emotional adjustments of community mental health center patients. Journal of Consulting and Clinical Psychology, 48, 366-374. Walen, S., DiGiuseppe, R., & Wessler, R. (1980). A Practitioner's guide to rationalemotive therapy. New York: Oxford University Press. Offprints. Requests for offprints and correspondence concerning this article should be addressed to R. DiGiuseppe, Department of Psychology, St. John's University, Jamaica, NY 11439.

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