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.
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.
To test the feasibility and acceptability of implementing an evidence-based, peer-delivered mental health intervention for Somali women in Minnesota, and to assess the impact of the intervention on the mental health of those who received the training. In a feasibility study, 11 Somali female community health workers were trained to deliver an 8-session cognitive behavioral therapy intervention. Each of the trainers recruited 5 participants through community outreach, resulting in 55 participants in the intervention. Self-assessed measures of mood were collected from study participants throughout the intervention, and focus groups were conducted. The 55 Somali women who participated recorded significant improvements in mood, with self-reported decreases in anxiety and increases in happiness. Focus group data showed the intervention was well received, particularly because it was delivered by a fellow community member. Participants reported gaining skills in problem solving, stress reduction, and anger management. Participants also felt that the intervention helped to address some of the stigma around mental health in their community. Delivery of cognitive behavioral therapy by a community health workers offered an acceptable way to build positive mental health in the Somali community.
Pratt, R., Ahmed, N., Noor, S., Sharif, H., Raymond, N., & Williams C. (December 31, 2015) Addressing Behavioral Health Disparities for Somali Immigrants Through Group Cognitive Behavioral Therapy Led by Community Health Workers Journal of Immigrant and Minority Health.
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