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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.

CBT plus Medication is Effective for Chronic Migraine in Children and Adolescents

According to a recent study published in JAMA, cognitive behavior therapy (CBT) plus amitriptyline (a tricyclic antidepressant used in the treatment of migraines) may be an effective treatment for chronic migraines in children and adolescents. In the current study, researchers compared the efficacy of CBT plus amitriptyline versus headache education plus amitriptyline. Participants included 135 youth aged 10 to 17 diagnosed with chronic migraine. They were randomized to either the CBT plus amitriptyline group (n = 64) or headache education plus amitriptyline group (n = 71). Participants received either 10 CBT sessions or 10 headache education sessions involving equivalent time and therapist attention. At post-treatment, 66% in the CBT group had at least a 50% reduction in headache days versus 36% in the headache education group. At the 12-month follow up, 86% in the CBT group had at least a 50% reduction in headache days versus 69% in the headache education group. These findings support the efficacy of CBT in the treatment of chronic migraine among children and adolescents.

Powers, S. W., Kashikar-Zuck, S. M., Allen, J. R., LeCates, S. L., Slater, S. K., Zafar, M., Kabbouche, M. A., … Hershey, A. D. (December 25, 2013). Cognitive Behavioral Therapy Plus Amitriptyline for Chronic Migraine in Children and Adolescents. Jama, 310, 24, 2622.

CBT for Children and Adolescents

Cognitive Behavior Therapy for Children and Adolescents

Dr. Aaron Beck at Beck Institute's CBT for Children and Adolescent's Workshop

For more pictures from our recent CBT for Children and Adolescents Workshop visit our Facebook page.

Social Competence Influences CBT Treatment Response in Anxious Youth

According to a recent study published in Child Psychiatry & Human Development, there are significant associations between measures of social functioning and the severity of a child’s principal anxiety disorder. Further, social competence is likely to influence several key elements of cognitive behavior therapy (CBT) and CBT treatment response.

Participants (161, ages 7-14) diagnosed with a principal anxiety disorder participated in a randomized clinical trial. They received either individual CBT treatment, family CBT treatment, or an active comparison treatment (family-based education, support, and attention). According to results, children rated to be more socially competent by their mothers prior to treatment were more likely to respond positively to CBT and were less likely to have their initial anxiety continue to meet diagnostic criteria at a 1-year follow up, than children rated less socially competent. Future research should explore the mechanisms through which social competence may impact treatment response and mediators of the relationship better poor social functioning and anxiety in youth.

Settipani, C. A., Kendall, P.C. (2012). Social functioning in Youth with Anxiety Disorders: Association with Anxiety Severity and Outcomes from Cognitive-Behavioral Therapy. Child Psychiatry & Human Development.

CBT for Children with Anxiety Disorders: Comparison of a Child + Parent Condition Versus a Parent Only Condition

A study published in Behaviour Therapy and Research compared the efficacy of group-based cognitive behavior therapy (GCBT) delivered to young, anxious children and their parents versus GCBT delivered to parents only. Results showed no significant difference between the two conditions. These findings suggest that GCBT delivered exclusively to parents of young, anxious children may be a feasible treatment alternative for improving accessibility to efficacious treatments for children with anxiety disorders.

Waters, A.M., Ford, L.A., Wharton, T.A., Cobham, V.E. (2009) Cognitive-behavioural therapy for young children with anxiety disorders: Comparison of a Child + Parent condition versus a Parent Only condition. Behaviour Research and Therapy, 47(8), 654-662.

To learn more about CBT for children and adolescents attend one of our upcoming workshops: www.beckinstitute.org/cbt-workshops/cbt-for-children-and-adolescents.

Cultural Differences in CBT for Children

A participant from Singapore explains a common core belief based in all-or-nothing thinking. Dr. Beck recalls a patient vignette which helps describe a similar pattern of thinking (to the described students in Singapore) and the procedure Dr. Beck followed for treatment. For more information about CBT training or to register for a workshop directed by Drs. Judith and Aaron Beck visit our CBT Workshops page.

MRSI Correlates of CBT in Pediatric OCD

A recent study published in Progress in Neuro-Psychopharmacological & Biological Psychiatry found that Cognitive Behavior Therapy (CBT) is effective in altering metabolic hyperactivity of neurochemicals associated with OCD symptoms in pediatric obsessive-compulsive disorder (OCD) patients. OCD is an anxiety disorder in which individuals experience obsessive, anxiety producing thoughts and seek relief through engaging in repetitive, compulsive behaviors. The current study investigated effects of CBT on neurochemicals in pediatric OCD. A variation of magnetic resonance imaging (MRI) was used to study the effects of CBT on specific neurochemicals in specific areas of the brain that are associated with OCD.

The participants included five, medication-free patients with diagnosed OCD and no prior exposure to CBT. The average age of the participants was 13. Each participant underwent exposure-based CBT once a week for 12 weeks. OCD symptom severity was assessed before and after the 12-week intervention using the Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS). MRIs were also conducted on each patient before and after the study to measure neurochemical levels.

Certain neurochemicals associated with OCD significantly contribute to the obsessive thoughts and ritualistic behaviors characteristic of the disorder. Normally, these chemicals work in tandem in a specific neural pathway to moderate the initiation, sustainability and eventual ending of behavioral routines. In individuals with OCD, however, there is increased activity in this pathway, creating an imbalance in activity. When patients adhere to exposure-based CBT techniques, the chemicals have a chance to correct the imbalance, allowing the brain, body and behaviors to synchronize. In this study, four of the five participants had significant post-CBT decreases in the chemicals known to negatively affect the behavioral routine cycle. Though not statistically significant, participants also had a 32.8% decline in symptom severity based on their post-CBT CY-BOCS score. It is evident that CBT, which is based on modifying maladaptive thoughts and behaviors, can actually alter abnormal brain chemistry in OCD patients which helps reduce symptoms of the disorder.

O’Neill, J., Piacentini, J.C., Chang, S., Levitt, G. J., Rozenman, M., Bergman, L.,…McCraken, J.T. (2011). MRSI correlates of cognitive-behavioral therapy in pediatric obsessive- compulsive disorder. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 36 (2012) 161-168.

Urban African American Youth Exposed to Community Violence: A School-Based Anxiety Preventive Intervention Efficacy Study

Violence in schools, neighborhoods and communities has reached critically high levels in recent years.  Exposure to community violence may profoundly affect children’s development from early childhood to adolescence and beyond.

Cooley-Strickland et al. evaluated the efficacy of a school-based anxiety prevention program among urban children exposed to community violence. Higher rates of community violence and crime are experienced by African Americans living in low-income, urban neighborhoods than urban European Americans. Persistent worry about one’s own health and safety, or the health and safety of a loved one, is likely to interfere with a child’s ability to function in developmentally appropriate, academically successful, and health ways. Furthermore, positive correlations between exposure to community violence and anxiety have been demonstrated in previous research.

In this study, 3rd-5th grade students from two Title 1 schools in Baltimore, MD participated in 13 bi-weekly, one-hour group sessions of a modified version of FRIENDS, a cognitive-behavioral anxiety intervention program. FRIENDS utilizes core components of CBT (exposure, relaxation, cognitive strategies) and targets the primary symptoms of anxiety (physiological, cognitive, behavioral). The goal of this study was to decrease anxiety symptoms and prevent the onset of severe anxiety disorders among the sample of low-income, urban African American children exposed to community violence.

The children who participated in the FRIENDS (experimental) group showed lower levels of victimization and fewer life stressors than the control group. The cognitive behavioral skills taught in the program coupled with an emphasis on utilizing healthy coping techniques for managing anxiety, may have contributed to this finding. While the intervention did not specifically target academic skills, the participants’ in the FRIENDS group showed improvement in standardized reading and mathematics scores, whereas the control group showed improvement in reading scores only.

CBT based therapies and interventions, such as the FRIENDS program, can be effective in reducing and preventing anxiety disorders in low-income children from urban public schools. Enhancing the coping skills of these children who experience greater life stressors and have less social support can help reduce the effects of community violence exposure. This can contribute to lower levels of anxiety and consequently higher levels of appropriate development and academic success.

Cooley-Strickland, M.R., Griffin, R.S., Darney, D., Otte, K., Ko, J. (2011). Urban African American Youth   Exposed to Community Violence: A School-Based Anxiety Preventive Intervention Efficacy Study.  Journal of Prevention & Intervention in the Community, 39(2), 149-166.