Rational emotive behavior therapy
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|Rational emotive behavior therapy|
Rational emotive behavior therapy (REBT), previously called rational therapy and rational emotive therapy, is a comprehensive, active-directive, philosophically and empirically based psychotherapy which focuses on resolving emotional and behavioral problems and disturbances and enabling people to lead happier and more fulfilling lives. REBT was created and developed by the American psychotherapist and psychologist Albert Ellis who was inspired by many of the teachings of Asian, Greek, Roman and modern philosophers. REBT is one form of cognitive behavior therapy (CBT) and was first expounded by Ellis in the mid-1950s; development continued until his death in 2007.
Rational Emotive Behavior Therapy (REBT) is both a psychotherapeutic system of theory and practices and a school of thought established by Albert Ellis. Originally called rational therapy, it was renamed to rational emotive therapy in 1959, then to the current term in 1992. This approach was one of the first of the cognitive behavior therapies, as it was laid out in articles Ellis first published in 1956, nearly a decade before Aaron Beck first set forth his cognitive therapy.
Precursors of certain fundamental aspects of Rational Emotive Behavior Therapy have been identified in ancient philosophical traditions, particularly Stoicism. For example, Ellis' first major publication on rational therapy describes the philosophical basis of it as the principle that a person is rarely affected emotionally by outside things but rather by ‘his perceptions, attitudes, or internalized sentences about outside things and events.' He adds,
This principle, which I have inducted from many psychotherapeutic sessions with scores of patients during the last several years, was originally discovered and stated by the ancient Stoic philosophers, especially Zeno of Citium (the founder of the school), Chrysippus [his most influential disciple], Panaetius of Rhodes (who introduced Stoicism into Rome), Cicero, Seneca, Epictetus, and Marcus Aurelius. The truths of Stoicism were perhaps best set forth by Epictetus, who in the first century A.D. wrote in the Enchiridion: “Men are disturbed not by things, but by the views which they take of them.” Shakespeare, many centuries later, rephrased this thought in Hamlet: “There’s nothing good or bad but thinking makes it so.”
One of the fundamental premises of REBT is that humans, in most cases, do not merely get upset by unfortunate adversities, but also by how they construct their views of reality through their language, evaluative beliefs, meanings and philosophies about the world, themselves and others. This concept has been attributed as far back as the Greek Philosopher Epictetus, who is often cited as utilizing similar ideas in antiquity. In REBT, clients usually learn and begin to apply this premise by learning the A-B-C-model of psychological disturbance and change. The A-B-C model states that it normally is not merely an A, adversity (or activating event) that contributes to disturbed and dysfunctional emotional and behavioral Cs, consequences, but also what people B, believe about the A, adversity. A, adversity can be either an external situation or a thought or other kind of internal event, and it can refer to an event in the past, present, or future.
The Bs, beliefs that are most important in the A-B-C model are explicit and implicit philosophical meanings and assumptions about events, personal desires, and preferences. The Bs, beliefs that are most significant are highly evaluative and consist of interrelated and integrated cognitive, emotional and behavioral aspects and dimensions. According to REBT, if a person's evaluative B, belief about the A, activating event is rigid, absolutistic and dysfunctional, the C, the emotional and behavioral consequence, is likely to be self-defeating and destructive. Alternatively, if a person's evaluative B, belief is preferential, flexible and constructive, the C, the emotional and behavioral consequence is likely to be self-helping and constructive.
Through REBT, by understanding the role of their mediating, evaluative and philosophically based illogical, unrealistic and self-defeating meanings, interpretations and assumptions in upset, people often can learn to identify them, begin to D, dispute, refute, challenge and question them, distinguish them from healthy constructs, and subscribe to more constructive and self-helping constructs.
The REBT framework assumes that humans have both innate rational (meaning self-helping, socially helping, and constructive) and irrational (meaning self-defeating, socially defeating, and unhelpful) tendencies and leanings. REBT claims that people to a large degree consciously and unconsciously construct emotional difficulties such as self-blame, self-pity, clinical anger, hurt, guilt, shame, depression and anxiety, and behaviors and behavior tendencies like procrastination, over-compulsiveness, avoidance, addiction and withdrawal by the means of their irrational and self-defeating thinking, emoting and behaving. REBT is then applied as an educational process in which the therapist often active-directively teaches the client how to identify irrational and self-defeating beliefs and philosophies which in nature are rigid, extreme, unrealistic, illogical and absolutist, and then to forcefully and actively question and dispute them and replace them with more rational and self-helping ones. By using different cognitive, emotive and behavioral methods and activities, the client, together with help from the therapist and in homework exercises, can gain a more rational, self-helping and constructive rational way of thinking, emoting and behaving. One of the main objectives in REBT is to show the client that whenever unpleasant and unfortunate activating events occur in people's lives, they have a choice of making themselves feel healthily and self-helpingly sorry, disappointed, frustrated, and annoyed, or making themselves feel unhealthily and self-defeatingly horrified, terrified, panicked, depressed, self-hating, and self-pitying. By attaining and ingraining a more rational and self-constructive philosophy of themselves, others and the world, people often are more likely to behave and emote in more life-serving and adaptive ways.
Albert Ellis posits three major insights of REBT:
Insight 1 – People seeing and accepting the reality that their emotional disturbances at point C are only partially caused by the activating events or adversities at point A that precede C. Although A contributes to C, and although disturbed Cs (such as feelings of panic and depression) are much more likely to follow strong negative As (such as being assaulted or raped), than they are to follow weak As (such as being disliked by a stranger), the main or more direct cores of extreme and dysfunctional emotional disturbances (Cs) are people’s irrational beliefs — the "absolutistic" (inflexible) "musts" and their accompanying inferences and attributions that people strongly believe about the activating event.
Insight 2 – No matter how, when, and why people acquire self-defeating or irrational beliefs (i.e. beliefs that are the main cause of their dysfunctional emotional-behavioral consequences), if they are disturbed in the present, they tend to keep holding these irrational beliefs and continue upsetting themselves with these thoughts. They do so not because they held them in the past, but because they still actively hold them in the present (often unconsciously), while continuing to reaffirm their beliefs and act as if they are still valid. In their minds and hearts, the troubled people still follow the core "musturbatory" philosophies they adopted or invented long ago, or ones they recently accepted or constructed.
Insight 3 – No matter how well they have gained insights 1 and 2, insight alone rarely enables people to undo their emotional disturbances. They may feel better when they know, or think they know, how they became disturbed, because insights can feel useful and curative. But it is unlikely that people will actually get better and stay better unless they have and apply insight 3, which is that there is usually no way to get better and stay better except by continual work and practice in looking for and finding one’s core irrational beliefs; actively, energetically, and scientifically disputing them; replacing one’s absolute "musts" (rigid requirements about how things should be) with more flexible preferences; changing one's unhealthy feelings to healthy, self-helping emotions; and firmly acting against one’s dysfunctional fears and compulsions. Only by a combined cognitive, emotive, and behavioral, as well as a quite persistent and forceful attack on one's serious emotional problems, is one likely to significantly ameliorate or remove them, and keep them removed.
"REBT assumes that human thinking, emotion, and action are not really separate or disparate processes, but that they all significantly overlap and are rarely experienced in a pure state. Much of what we call emotion is nothing more nor less than a certain kind — a biased, prejudiced, or strongly evaluative kind — of thought. But emotions and behaviors significantly influence and affect thinking, just as thinking influences emotions and behaviors. Evaluating is a fundamental characteristic of human organisms and seems to work in a kind of closed circuit with a feedback mechanism: First, perception biases response, and then response tends to bias subsequent perception. Also, prior perceptions appear to bias subsequent perceptions, and prior responses appear to bias subsequent responses. What we call feelings almost always have a pronounced evaluating or appraisal element."
REBT then generally proposes that many of these self-defeating cognitive, emotive and behavioral tendencies are both innately biological and indoctrinated early in and during life, and further grow stronger as a person continually revisits, clings and acts on them. Ellis alludes to similarities between REBT and the general semantics when explaining the role of irrational beliefs in self-defeating tendencies, citing Alfred Korzybski as a significant modern influence on this thinking.
REBT differs from other clinical approaches like psychoanalysis in that it places little emphasis on exploring the past, but instead focuses on changing the current evaluations and philosophical thinking-emoting and behaving in relation to themselves, others and the conditions under which people live.
One of the main pillars of REBT is that irrational and dysfunctional ways and patterns of thinking, feeling and behaving are contributing to much, though hardly all, human disturbance and emotional and behavioral self-defeatism and social defeatism. REBT generally teaches that when people turn flexible preferences, desires and wishes into grandiose, absolutistic and fatalistic dictates, this tends to contribute to disturbance and upsetness.
Albert Ellis has suggested three core beliefs or philosophies that humans tend to disturb themselves through:
|"I absolutely MUST, under practically all conditions and at all times, perform well (or outstandingly well) and win the approval (or complete love) of significant others. If I fail in these important—and sacred—respects, that is awful and I am a bad, incompetent, unworthy person, who will probably always fail and deserves to suffer."||"Other people with whom I relate or associate, absolutely MUST, under practically all conditions and at all times, treat me nicely, considerately and fairly. Otherwise, it is terrible and they are rotten, bad, unworthy people who will always treat me badly and do not deserve a good life and should be severely punished for acting so abominably to me."||"The conditions under which I live absolutely MUST, at practically all times, be favorable, safe, hassle-free, and quickly and easily enjoyable, and if they are not that way it's awful and horrible and I can't bear it. I can't ever enjoy myself at all. My life is impossible and hardly worth living."|
|Holding this belief when faced with adversity tends to contribute to feelings of anxiety, panic, depression, despair, and worthlessness.||Holding this belief when faced with adversity tends to contribute to feelings of anger, rage, fury, and vindictiveness.||Holding this belief when faced with adversity tends to contribute to frustration and discomfort, intolerance, self-pity, anger, depression, and to behaviors such as procrastination, avoidance, and inaction.|
REBT commonly posits that at the core of irrational beliefs there often are explicit or implicit rigid demands and commands, and that extreme derivatives like awfulizing, frustration intolerance, people deprecation and over-generalizations are accompanied by these. According to REBT the core dysfunctional philosophies in a person's evaluative emotional and behavioral belief system, are also very likely to contribute to unrealistic, arbitrary and crooked inferences and distortions in thinking. REBT therefore first teaches that when people in an insensible and devout way overuse absolutistic, dogmatic and rigid "shoulds", "musts", and "oughts", they tend to disturb and upset themselves.
Further REBT generally posits that disturbed evaluations to a large degree occur through over-generalization, wherein people exaggerate and globalize events or traits, usually unwanted events or traits or behavior, out of context, while almost always ignoring the positive events or traits or behaviors. For example, awfulizing is partly mental magnification of the importance of an unwanted situation to a catastrophe or horror, elevating the rating of something from bad to worse than it should be, to beyond totally bad, worse than bad to the intolerable and to a "holocaust". The same exaggeration and overgeneralizing occurs with human rating, wherein humans come to be arbitrarily and axiomatically defined by their perceived flaws or misdeeds. Frustration intolerance then occurs when a person perceives something to be too difficult, painful or tedious, and by doing so exaggerates these qualities beyond one's ability to cope with them.
Essential to REBT theory is also the concept of secondary disturbances which people sometimes construct on top of their primary disturbance. As Ellis emphasizes:
"Because of their self-consciousness and their ability to think about their thinking, they can very easily disturb themselves about their disturbances and can also disturb themselves about their ineffective attempts to overcome their emotional disturbances."
As would be expected, REBT argues that mental wellness and mental health to a large degree results from an adequate amount of self-helping, flexible, logico-empirical ways of thinking, emoting and behaving. When a perceived undesired and stressful activating event occurs, and the individual is interpreting, evaluating and reacting to the situation rationally and self-helpingly, then the resulting consequence is, according to REBT, likely to be more healthy, constructive and functional. This does not by any means mean that a relatively un-disturbed person never experiences negative feelings, but REBT does hope to keep debilitating and un-healthy emotions and subsequent self-defeating behavior to a minimum. To do this REBT generally promotes a flexible, un-dogmatic, self-helping and efficient belief system and constructive life philosophy about adversities and human desires and preferences.
REBT clearly acknowledges that people, in addition to disturbing themselves, also are innately constructivists. Because they largely upset themselves with their beliefs, emotions and behaviors, they can be helped to, in a multimodal manner, dispute and question these and develop a more workable, more self-helping set of constructs.
REBT generally teaches and promotes:
- That the concepts and philosophies of life of unconditional self-acceptance, other-acceptance, and life-acceptance are effective philosophies of life in achieving mental wellness and mental health.
- That human beings are inherently fallible and imperfect and that they had better accept their and other human being's totality and humanity, while at the same time not like some of their behaviors and characteristics. That they are better off not measuring their entire self or their "being" and give up the narrow, grandiose and ultimately destructive notion to give themselves any global rating or report card. This is partly because all humans are continually evolving and are far too complex to accurately rate; all humans do both self-defeating / socially defeating and self-helping / socially helping deeds, and have both beneficial and un-beneficial attributes and traits at certain times and in certain conditions. REBT holds that ideas and feelings about self-worth are largely definitional and are not empirically confirmable or falsifiable.
- That people had better accept life with its hassles and difficulties not always in accordance with their wants, while trying to change what they can change and live as elegantly as possible with what they cannot change.
As explained, REBT is a therapeutic system of both theory and practices; generally one of the goals of REBT is to help clients see the ways in which they have learned how they often needlessly upset themselves, teach them how to "un-upset" themselves and then how to empower themselves to lead happier and more fulfilling lives. The emphasis in therapy is generally to establish a successful collaborative therapeutic working alliance based on the REBT educational model. Although REBT teaches that the therapist or counsellor had better demonstrate unconditional other-acceptance or unconditional positive regard, the therapist is not necessarily always encouraged to build a warm and caring relationship with the client. The tasks of the therapist or counselor include understanding the client’s concerns from his point of reference and work as a facilitator, teacher and encourager.
In traditional REBT, the client together with the therapist, in a structured active-directive manner, often work through a set of target problems and establish a set of therapeutic goals. In these target problems, situational dysfunctional emotions, behaviors and beliefs are assessed in regards to the client's values and goals. After working through these problems, the client learns to generalize insights to other relevant situations. In many cases after going through a client's different target problems, the therapist is interested in examining possible core beliefs and more deep rooted philosophical evaluations and schemas that might account for a wider array of problematic emotions and behaviors. Although REBT much of the time is used as a brief therapy, in deeper and more complex problems, longer therapy is promoted.
In therapy, the first step often is that the client acknowledges the problems, accepts emotional responsibility for these and has willingness and determination to change. This normally requires a considerable amount of insight, but as originator Albert Ellis explains:
"Humans, unlike just about all the other animals on earth, create fairly sophisticated languages which not only enable them to think about their feeling, their actions, and the results they get from doing and not doing certain things, but they also are able to think about their thinking and even think about thinking about their thinking."
Through the therapeutic process, REBT employs a wide array of forceful and active, meaning multimodal and disputing, methodologies. Central through these methods and techniques is the intent to help the client challenge, dispute and question their destructive and self-defeating cognitions, emotions and behaviors. The methods and techniques incorporate cognitive-philosophic, emotive-evocative-dramatic, and behavioral methods for disputation of the client's irrational and self-defeating constructs and helps the client come up with more rational and self-constructive ones. REBT seeks to acknowledge that understanding and insight are not enough; in order for clients to significantly change, they had better pinpoint their irrational and self-defeating constructs and work forcefully and actively at changing them to more functional and self-helping ones.
REBT posits that the client must work hard to get better, and in therapy this normally includes a wide array of homework exercises in day-to-day life assigned by the therapist. The assignments may for example include desensitization tasks, i.e., by having the client confront the very thing he or she is afraid of. By doing so, the client is actively acting against the belief that often is contributing significantly to the disturbance.
Another factor contributing to the brevity of REBT is that the therapist seeks to empower the client to help himself through future adversities. REBT only promotes temporary solutions if more fundamental solutions are not found. An ideal successful collaboration between the REBT therapist and a client results in changes to the client's philosophical way of evaluating himself or herself, others, and his or her life, which will likely yield effective results. The client then moves toward unconditional self-acceptance, other-acceptance and life-acceptance while striving to live a more self-fulfilling and happier life.
REBT and CBT in general have a substantial and strong research base to verify and support both their psychotherapeutic efficiency and their theoretical underpinnings. A great quantity of scientific empirical studies has proven REBT to be an effective and efficient treatment for many kinds of psychopathology, conditions and problems. A vast amount of outcome and experimental studies support the effectiveness of REBT and CBT. Recently, REBT randomized clinical trials have offered a positive view on the efficacy of REBT.
In general REBT is arguably one of the most investigated theories in the field of psychotherapy and a large amount of clinical experience and a substantial body of modern psychological research have validated and substantiated many of REBTs theoretical assumptions on personality and psychotherapy.
Limitations and critique
Some critiques have been given on some of the clinical research that has been done on REBT both from within and by others. For instance originator Albert Ellis has on occasions emphasized the difficulty and complexity of measuring psychotherapeutic effectiveness, since many studies only tend to measure whether clients merely feel better after therapy instead of them getting better and staying better. Ellis has also criticized studies for having limited focus primarily to cognitive restructuring aspects, as opposed to the combination of cognitive, emotive and behavioral aspects of REBT. As REBT has been subject to criticisms during its existence, especially in its early years, REBT theorists have a long history of publishing and addressing those concerns. It has also been argued by Ellis and by other clinicians that REBT theory on numerous occasions has been misunderstood and misconstrued both in research and in general.
Some have criticized REBT for being harsh, formulaic and failing to address deep underlying problems. This has been cogently refuted by REBT theorists who have pointed out that a careful study of REBT shows that it is both philosophically deep, humanistic and individualized collaboratively working on the basis of the client’s point of reference. They have further pointed out that REBT utilizes an integrated and interrelated methodology of cognitive, emotive-experiential and behavioral interventions. Others have questioned REBTs view of rationality, both radical constructivists who have claimed that reason and logic are subjective properties and those who believe that reason can be objectively determined. REBT theorists have refuted these claims by maintaining that REBT raises objections to clients' irrational choices and conclusions as a working hypothesis and through collaborative efforts demonstrate the irrationality on practical, functional and social consensual grounds. In 1998 when asked what the main criticism on REBT was, Albert Ellis replied that it was the claim that it was too rational and not dealing sufficiently enough with emotions. He repudiated the claim by saying that REBT on the contrary emphasized that thinking, feeling, and behaving are interrelated and integrated, and that it includes a vast amount of both emotional and behavioral methods in addition to cognitive ones.
Ellis has himself in very direct terms criticized opposing approaches such as psychoanalysis, transpersonal psychology and abreactive psychotherapies in addition to on several occasions questioning some of the doctrines in certain religious systems, spiritualism and mysticism. Many, including REBT practitioners, have warned against dogmatizing and sacredizing REBT as a supposedly perfect psychological cure-all and panacea. Prominent REBTers have promoted the importance of high quality and programmatic research, including originator Ellis, a self-proclaimed "passionate skeptic". He has on many occasions been open to challenges and acknowledged errors and inefficiencies in his approach and concurrently revised his theories and practices. In general, with regard to cognitive-behavioral psychotherapies' interventions, others have pointed out that as about 30–40% of people are still unresponsive to interventions, that REBT could be a platform of reinvigorating empirical studies on the effectiveness of the cognitive-behavioral models of psychopathology and human functioning.
REBT has generally been developed, revised and augmented through the years, as understanding, knowledge and science about psychology and psychotherapy have progressed. This includes its theoretical concepts, practices and methodology. The teaching of scientific thinking, reasonableness and un-dogmatism has been inherent in REBT as an approach, and these ways of thinking have been part of REBT's empiricism and skepticism.
Applications and interfaces
Applications and interfaces of REBT are used with a broad range of clinical problems in traditional psychotherapeutic settings such as individual-, group- and family therapy. It is used as a general treatment for a vast number of different conditions and psychological problems normally associated with psychotherapy.
In addition, REBT is used with non-clinical problems and problems of living through counselling, consultation and coaching settings dealing with problems including relationships, social skills, career changes, stress management, assertiveness training, grief, problems with aging, money, weight control etc.
REBT also has many interfaces and applications through self-help resources, phone and internet counseling, workshops & seminars, workplace and educational programmes, etc. This includes Rational Emotive Education (REE) where REBT is applied in education settings, Rational Effectiveness Training in business and work-settings and SMART Recovery (Self Management And Recovery Training) in supporting those in addiction recovery, in addition to a wide variety of specialized treatment strategies and applications.
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- Ellis, A. (2004) Rational Emotive Behavior Therapy: It Works for Me—It Can Work for You. Amherst, NY: Prometheus Books.
- McMahon, J., &d Vernon, A. (2010) Albert Ellis: Evolution of a Revolution: Selections from the Writings of Albert Ellis, Ph.D. Fort Lee, NJ: Barricade Books.
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- Velten, E. (2010) Under the Influence: Reflections of Albert Ellis in the Work of Others. Tucson, AZ: See Sharp Press
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- Beck, A. (1970). Cognitive therapy: Nature and relation to behavior therapy. Behavior Therapy, 1(2), 184–200.
- Robertson, D (2010). The Philosophy of Cognitive-Behavioural Therapy: Stoicism as Rational and Cognitive Psychotherapy. London: Karnac. ISBN 978-1-85575-756-1.
- Ellis, Albert (1962) Reason and Emotion in Psychotherapy. p. 54
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- Dryden W., & Neenan M. (2003). Essential Rational Emotive Behaviour Therapy. Wiley.
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- Ellis, A. (2001). Feeling better, getting better, staying better. Impact Publishers
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- "REBT particularly follows Korzybski in this respect..." Albert Ellis in The Albert Ellis reader: A guide to well-being using rational emotive behavior therapy, p. 306. Google Books preview retrieved August 18, 2010.
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- Philosophy in Psychotherapy: Albert Ellis interview by Jeffrey Mishlove
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- Ellis A., Abrams M. & Abrams L. (2008). Theories of Personality. Sage Press
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- Albert Ellis and Michael Abrams, PhD, and Lidia Abrams, PhD. Theories of Personality: Critical Perspectives, New York: Sage Press, 7/2008 ISBN 978-1-4129-1422-2 (This was his final work, published posthumously).
- Albert Ellis & Windy Dryden, The Practice of Rational Emotive Behavior Therapy (2nd ed.); Springer Publishing, 2007. ISBN 978-0-8261-2216-2
- Windy Dryden & Michael Neenan, Getting Started with REBT; Routledge, 2005. ISBN 978-1-58391-939-2
- Windy Dryden, Rational Emotive Behaviour Therapy in a Nutshell (Counselling in a Nutshell); Sage Publications, 2005. ISBN 978-1-4129-0770-5
- Windy Dryden, Fundamentals of Rational Emotive Behaviour Therapy: A Training Manual; John Wiley & Sons, 2002. ISBN 1-86156-347-7
- Windy Dryden, Rational Emotive Behaviour Therapy; Theoretical Developments; Brunner-Routledge, 2003. ISBN 1-58391-272-X
- Albert Ellis, Overcoming Destructive Beliefs, Feelings, and Behaviors: New Directions for Rational Emotive Behavior Therapy; Prometheus Books, 2001. ISBN 1-57392-879-8
- Albert Ellis, Feeling better, getting better, staying better; Impact Publishers, 2001. ISBN 1-886230-35-8
- Windy Dryden et al., A Practitioner's Guide to Rational-Emotive Therapy; Oxford University Press, 1992. ISBN 0-19-507169-7
- Albert Ellis et al., A Guide to Rational Living (3rd rev ed.); Wilshire Book Company, 1997. ISBN 0-87980-042-9
- Stevan Lars Nielsen, W. Brad Johnson & Albert Ellis, Counseling and Psychotherapy With Religious Persons: A Rational Emotive Behavior Therapy Approach; Lawrence Erlbaum, 2001. ISBN 0-8058-2878-8.
- Windy Dryden, Raymond Di Giuseppe & Michael Neenan, A Primer on Rational-Emotive Behavior Therapy (2nd ed.); Research Press, 2002. ISBN 978-0-87822-478-4
- Albert Ellis & Catharine MacLaren, Rational Emotive Behavior Therapy: A Therapist's Guide (2nd ed.); Impact Publishers, 2005. ISBN 978-1-886230-61-3
||This article's use of external links may not follow Wikipedia's policies or guidelines. (November 2014)|
- The Albert Ellis Institute
- REBT Network
- The Centre for Rational Emotive Behavior Therapy
- Association for Rational Emotive Behaviour Therapy
- UK Centre for Rational Emotive Behaviour Therapy
- Rational.org New Zealand
- International Institute for the Advanced Studies of Psychotherapy and Applied Mental Health
- Journal of Rational-Emotive and Cognitive Behaviour Therapy
- Dr Debbie Joffe Ellis,Wife of Dr Albert Ellis and REBT Lecturer
- National Association of Cognitive-Behavioral Therapists
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