Evil Pink Monsters and the Use of Externalization in Child CBT

Elisa Nebolsine

Elisa Nebolsine, LCSW

On my desk sits a stack of pictures that includes: “Evil Pink Monster,” “Bob, the angry wolf,” and “Enfado,” a small bird that breathes out long flames of anger.  These pictures, all externalized images of emotion, play a crucial role in my clinical work with children.  CBT is a problem-specific type of therapy, and as such, treatment goals reflect the identified problems, including those embodied in the monsters and birds on my desk.  Kids think differently from adults, so it may not be surprising that CBT looks and works a little differently with children and adolescents.


Sara (not her real name) is the artist who created “Evil Pink Monster.”  When she came into my office the other day, she wanted to make sure we included a recent “Pink Monster” episode in our agenda. Sara described an incident where she had acted verbally aggressive towards her sibling—an ongoing issue.  When our work first began, Sara had explained to me that she was “just not a nice kid. I’m not one of those good kids, I’m just not.”  As we delved deeper, it became clear that Sara had a great deal of difficulty regulating her emotions, and she often over-reacted to situations.


“The person is not the problem, the problem is the problem,” wrote narrative therapist Michael White.  When a child thinks that she’s a problem kid because she always acts out in school or causes conflict at home, it’s harder to help her make changes.  In that narrative, the problem is her.  CBT involves reappraisal of the situation and a willingness to look at the problem through different perspectives.  When the child feels as if she is the literal problem, it becomes harder for her to objectively view the situation and her reactions.  In CBT with kids, this is where the process of externalizing the problem becomes very helpful.  It’s amazing how much easier it is to tackle a situation when a kid doesn’t feel like she is the sole reason for the problem.


Here’s how it works:  Sara, age 9, had struggled with her anger for quite some time.  She entered into CBT with a clear sense that she was “messed up” and that she was at fault for causing stress in the family.  Every adult in her life had asked her why she did the things she did, and tried to talk with her rationally about making different choices.  The reality was that 9-year-old Sara didn’t have a good sense of why she acted the way she did, and she truly felt terrible about it.  Sara and I worked on identifying the automatic thoughts she had when she was angry.  These thoughts included: “It’s so unfair,” “This always happens—I always get blamed,” and “I hate them!”


As we wrote down Sara’s automatic thoughts and looked at her feelings (anger, frustration, sadness), we began to imagine what those thoughts and feelings would look like if they were an actual creature.  Sara, an excellent artist, began to draw out some designs. (If Sara had been reluctant to actually draw the image, we would have narrowed down the type of creature [monster, wolf, etc.] and googled clipart versions to get ideas).


Sara and I kept talking about what we imagined her anger looked like while she drew, and she was able to verbalize the experience of her emotions and to voice her automatic thoughts. “Something mean, that makes everything seem like it’s worse than it is.  He, like, gets in my head and tries to make me feel so bad and so mad.  He’s an evil little monster.”  Seeing a finger puppet on my desk, Sara picked it up and said, “This is it.  It’s him.”  Once we had a clear description and name for the monster (in this case, “Evil Pink Monster”) we had a new language for discussing the identified problem of her treatment—her difficulty controlling anger and regulating her emotions.Pink Monster


Sara had willingly come to therapy because she was unhappy with how little control she felt she had over her emotional responses, and because she felt guilty about how she acted.  By externalizing her anger into a concrete image, she was able to view the problem more objectively.  In this way it wasn’t all her fault; she wasn’t a bad kid; she just had an Evil Pink Monster inside that made things seem worse than they actually were.*


And now we needed to figure out how to battle the monster.


Traditional CBT techniques used to manage anger and regulate emotions now became more easily implemented into the therapy.  As Sara and I began the process of identifying behavioral and cognitive patterns, we simply shifted the language to reflect situations where the Evil Pink Monster was likely to be triggered.   In lieu of discussing behavioral patterns and automatic thoughts in traditional language, we discussed them through the lens of the Evil Pink Monster. As we rated the intensity of the anger response, we created our own 1-10 rating of how strong the Evil Pink Monster was at that moment (1 was Fuzzy Bunny strong and 10 was Godzilla Drinking Espresso strong).  And as we began to incorporate imagery into self-calming strategies, we often imagined the Evil Pink Monster on the beach drinking from a coconut or relaxing in a swimsuit under a palm tree.  The images in themselves were relaxing, but they were also funny, and the use of humor in coping strategies can often go a long way.


The process of externalization in CBT is frequently discussed in the OCD literature, but there is broader use for this technique.  Just as anger can be externalized into an evil pink monster, so can sadness be understood as Eeyore from Winnie the Pooh or, as one child described it “the blue monster that follows me around.”  A beautiful but anxious fourteen-year-old girl describe her social anxiety as a clown wearing plaid pants and braces. Her general anxiety was “the nasty storm cloud that always follows me around.”  Externalization doesn’t take away the patient’s responsibility to address their problems, but it does provide a tool to take away some of the self-blame, allowing for greater objectivity and greater change.


Externalization is one of many techniques pediatric CBT clinicians employ to make the process relatable, meaningful, and developmentally relevant.  Kids aren’t little adults, and their therapy looks a little different (and is often a lot more fun).


*To be clear, as a 9-year-old with no cognitive impairments, Sara could easily understand that we were using the monster as a symbolic representation of her anger. This technique would not be effective for children unable to differentiate between abstract and concrete ideas.


Learn more about CBT for Children and Adolescents at our upcoming workshop.

A Cognitive Explanation for Anger and Hostility

In this video from a recent Beck Institute Workshop, Dr. Aaron Beck discusses insights from his conversation with the Dalai Lama. Dr. Beck talks about anger and hostility, and provides a hypothesis for why people overreact with anger in certain situations. He describes anger as an exaggerated response to automatic thoughts about being threatened or devalued,which are rooted in deeply held exaggerated beliefs.

For CBT resources, visit our website.

CBT reduces fear and restores function for patients after cardiac defibrillator implantation

A recent article in Current Psychiatry reviews the negative effects on quality of life for people who receive an implantable cardioverter defibrillator (ICD) for irregular heart rhythms. These effects are particularly severe after the first experience of a “shock”—or ICD discharge. Though life-saving, these high-energy electrical discharges (shocks) are typically painful, and many patients experience anxiety, anger, and a sense of helplessness.

After a shock, patients instinctively begin to analyze the events or behaviors leading to the shock—which are often routine and not truly associated with the discharge event—so that they can avoid or even eliminate them from their lives. The fear of another shock and the fear of anything that could precipitate one can result in a “fear of fear” cycle. Patients may then start limiting their lifestyles so dramatically that depression ensues.

The authors suggest that this scenario can be avoided by routine cognitive-behavioral assessments during follow-up visits after the ICD implantation. Ideally, treatment consists of a combination of medication, psychotherapy, and support. With CBT, patients are guided to see how their thoughts about the device might be erroneous. Daily logs of ICD-related thoughts and cognitive re-structuring are useful CBT strategies.

In an example referenced in this article, eight sessions of CBT, which included exposure therapy and relaxation training, allowed a patient to resume most of his activities, and had a beneficial effect on his personal relationships and quality of life.

Study authors: D. P. Gibson, K. K. Kuntz  


When patients get angry in session

Judith S. Beck writes in:

Some therapists are quite concerned about their patients becoming angry at them. Yet when therapists respond sensitively, they can help patients learn important lessons.

The first thing I do when a patient becomes angry is to elicit their automatic thoughts and positively reinforce them, in a genuine way. “I’m so glad you told me that.” And I am glad. If there’s a problem, I want to know about it, so I can fix it.

Next, I conceptualize the problem in order to decide what to do. If I think the patient is correct, I’ll apologize – and in so doing, become a good role model. For example, a patient might be annoyed because he felt I was interrupting him too much. If he had that reaction, he’s right. I overestimated his tolerance for interruptions, so I can – again genuinely – say, “You know, I think you’re right. I did interrupt you too much. I’m sorry.”

If I don’t think I made a mistake, I can still genuinely say, “I’m sorry you’re feeling distressed,” because I truly am sorry if something I’ve said or done (or not said or done) made the patient feel worse. Then I try to figure out how to solve the problem, which might involve helping the patient evaluate his negative ideas about me or suggesting we change what we’re doing in the session.

Demonstrating to patients that interpersonal problems can be solved is sometimes one of the greatest benefits of therapy.

Alternatives to Drugs for Hyperactive Children? Psychotherapy Can Help


A recent NY Times article talks about the prevalence of ADHD in children, and parents who want to avoid drugs like Ritalin. The American Psychological Association in fact recommends that parents consider non-drug treatment first for children. The article discusses one family that used new parenting techniques to help with their son’s ADHD, and also says that Cognitive Behavior Therapy has been demonstrated to help teach children how to improve their anger, frustration, depression, and anxiety. We actually just posted on how nurses used Cognitive therapy to help children ages 7-18 — see below…