What is Cognitive Behaviour Therapy?
CBT is an umbrella term for a range of therapies that share the same underlying idea – that our emotional reactions to a situation are not caused by the situation itself but by what we think about it. This idea is not new. As Epictetus famously said long ago: “People are disturbed not by things but by the view they take of them”. Or Shakespeare: “There is nothing either good or bad but thinking makes it so.” Or Buddha: “We are what we think. All that we are arises with our thoughts. With our thoughts we make the world”. And the Bible: “Do not be conformed to this world, but be transformed by the renewal of your mind” (Romans 12:2, ESV).
So CBT is directed towards changing negative emotions by changing our thoughts and beliefs. Of course we often do this intuitively. For instance we may wait to make a decision till our mood and energy improves, understanding that “things look different in the morning”. In the CBT session, we challenge a person’s unhelpful beliefs by first identifying the feeling or feelings they want to change, then challenging or disputing the irrational beliefs contributing to their emotional disturbance. The person is also taught or encouraged towards alternative ways of acting which will disconfirm the irrational beliefs. They may for example watch the most popular kid in school to see how they handle being called a negative name, e.g. stupid, and whether they call names back. (Research shows that popular kids tend to deflect such comments rather than react to them.)
Then again in recent behavioural therapies (such as ACT), the person learns to ‘have’ or ‘watch’, not ‘buy’ a thought. But the end result is similar – freedom from the troubling thoughts that lead to troublesome emotions. So this helps take care of a person’s internal workings.
Cindy (8) came to therapy with anger issues. A CBT formulation notes that her anger stemmed from low frustration tolerance, the irrational belief that “things should be the way she wanted, when she wanted, because she wanted”. Cognitive Therapy involved helping her identify how she felt, the intensity of her feelings, where anger was in her body and how she behaved when angry. Using role play we identified what thoughts went through her head during situations where she felt frustrated and angry. Rigid ‘shoulds’, ‘oughts’ and ‘musts’ are a common source of anger. We then challenged those thoughts by (for example) asking her what she might say to a friend who said that she “should” have whatever she wanted of Cindy’s. Finally we worked out a system by which Cindy could practice building her emotional ‘muscle’ (frustration tolerance) by deliberately placing herself in situations where she might normally feel angry and saying to herself “It’s OK, I don’t really need this, I just would like it.” She received celebratory points toward something she wanted for each time she successfully met such a challenge.
But is this the whole story? Sometimes a child’s irrational or dysfunctional beliefs relate to a poor relationship history with a parent or caregiver. They become chronically anxious that their emotional needs will not be met or angry that they aren’t. They may cope with this by ramping up their attachment needs (ambivalent attachment) – the whiny, clingy, demanding drama king or queen – or by downplaying them (avoidant attachment), minimising their needs and wishes and becoming compulsively self-reliant. Children rely on adults to calm them as their nervous systems are not developed. But in some children this did not happen and their stress response is overdeveloped. When crisis strikes, these children are flooded with stress hormones yet can’t be calmed. They have low frustration tolerance because they cannot trust so have never learned how to turn to a capable adult for soothing. In their past, the significant others could not help them – perhaps they were poorly regulated themselves or perhaps they didn’t care. What the child wants and needs is a secure attachment and around 60% of children have this experience of relationships. They are confident of the caregiver’s availability and their effectiveness in being able to soothe away difficult feelings. Their neurological pattern is ‘set’ to calm rather than to mild or strong arousal. As a result they can regulate themselves during stressful times as well as turning to others when needed.
So here we are looking at their relationships and their relationship template. When the parent really wants to correct things with the child, we are also looking at relationship repair. Otherwise, in a sort of self-fulfilling prophecy, these children unwittingly set up these patterns with most people they meet. This is where Theraplay comes in.
What is Theraplay?
Theraplay is an experiential therapy that aims to change children’s “working models” or basic, non-conscious assumptions about whether they are secure or insecure in their relationships and whether their significant others can be depended on to help them with difficult feelings. These patterns are established in the first few years when the parent responds – or doesn’t – to the child’s signals and with constant repetition, eventually become a ‘working model’ in relation to attachment figures. This template is neurologically ‘set’ into the brain. Theraplay aims to change a child’s ‘implicit relational knowing’- what they think and believe about themselves and others in close relationships, their non-conscious expectation of what will come from interacting with another human being.
By providing emotionally corrective experiences which target the emotional control centres of the brain, Theraplay permits the child to experience him/herself as if she had been raised within a secure attachment relationship. Through the core Structuring, Nurturing, Engaging and Challenging activities of Theraplay, the child is helped to see himself in new ways – as unconditionally loveable, fun to be with, worthy of care and nurture, capable of growth and development. The parent figure (perhaps also after training or their own therapy) comes to be viewed as kind, calming, capable, emotionally available and attuned, and with the child’s interests at heart. A new and healthy relationship can result. Yet the activities are just the vehicle that facilitates connection. In a form of ‘behavioural bombardment’, the re-enactment of early attachment sequences that characterise Theraplay opens up a whole new behavioural repertoire in the child. These new attachment-relevant behaviours are then selectively shaped and reinforced in the therapy session. The child experiences him or herself in a new and positive way.
In addition, prior to the child-parent session, the parent has their own very important individual session with the therapist where parenting blocks are identified and they are coached in their co-therapist, co-regulatory role in the forthcoming session with their child.
When Cindy came for therapy, she was pouting and angry with her mother for bringing her. She was also nervous of the therapist. She had been badly neglected as a baby and was now in foster care. She later shared that she thought she had been taken from her birth mother because she was ‘naughty and bad’. She had intense mood swings and a tendency to hit out when people approached her. She had been referred on from another therapist for this very reason.
In the first few moments of the therapy session, mother and therapist ‘princess lifted’ Cindy into the room. The therapist gently placed her down into the beanbag, saying “Hi! I am glad you brought your lovely green eyes with you today!” Cindy hit her. The therapist responded instantly with empathy: “My, but you must be feeling scared as well as angry! You don’t know me yet and I guess you may not be feeling safe. Mum, check and let me know when our girl gets an “I’m feeling a bit safer” look in her eyes. (Pauses, then softly)- Hey, let me see those wonderful arm muscles! Wow! Your brain must have been telling you that you weren’t safe yet, so your muscles got tight. You are just fine as you are. You can relax any time you want by breathing deep and slow. (Therapist breathes deep and slow.) Now Mum, you measure your side and I’ll measure this side (measures upper arm girth with fruit tape and feeds her with it.) “I’ll bet you can’t use those strong muscles to make a fist through this newspaper” (stretching out a piece of newspaper and asking the mother to help hold it). “Can you hit this? (choose a picture on the sheet). Wow! You did it! How about two pieces of paper. Make sure you keep your thumb out! (Therapist blows on her thumb ‘for strength’) OK……When your Mum says “Now!”
Now Cindy’s face has changed from defensive fear to a shared moment of proud delight. Not only has her anger been redirected, but a competing behaviour of co-operation has been shaped and reinforced. Repeated moments such as these teach her that adults can ‘hold’, contain and redirect her anger, which is the start of a new ‘working model’ for her. These adults are bigger, stronger, wiser and kind. She might ‘lose’ it, but they don’t. They understand, don’t judge. They explain her behaviour to her in ways she can feel OK about and in attachment-related terms.
From there, we did more Structuring activities to reinforce this understanding – blowing a cotton ball back and forth (which also helps deep breathing), and jumping on a signal, e.g. a wink, to encourage eye contact. We also did Engaging activities, which teach her that she is unique and fun to be with. Hand clapping games and the Row Your Boat song were interspersed with Nurturing activities. These let her know that it is OK to have needs and that she will not be rejected for having them. So we painted her face, talking about her cute features and commenting how nice it was that her foster mother could get to enjoy her in this way.
From there it was only a small step to identify her irrational beliefs and place them in the context of a little girl who wanted to be loved but couldn’t believe anyone could or would – one who asked for things and felt she HAD to have them, no matter what. At this point, Cindy began to cry and her mother comforted her, stroking her hair and saying: “You know sometimes I think you feel you MUST have things because you never got them. But really this (kisses her on the top of her head) is what you need. The other things just fill the hole. You want those things but you don’t need them.” At this point, the therapist tells a story to illustrate the wants v. needs theme. The story outlined the thoughts, feelings and behaviours that accompany the belief that we “must” have something vs. simply wanting it. This is a good story to deal with Low Frustration Tolerance. Cindy remained attentive and engaged throughout.
The therapist then folded a piece of paper over, asking Cindy to draw herself “needing” (demanding) something on the top sheet, then underneath “wanting” (requesting) that same thing. The mother did the same on a separate piece of paper and they compared pictures. We then explored how she could talk to herself more helpfully next time she really wants something so that she doesn’t get so angry and upset.
The session ended with classic Theraplay Nurturing activities, feeding her, swinging her in a blanket, singing the Theraplay version of “Twinkle twinkle” then walking her out on her mother’s feet.
Her mother is instructed to do the CBT homework exercises with Cindy, which reinforces the learning and also helps the mother to be more effective as a parent. (Recall that the mother has had her own coaching session immediately prior to Cindy’s). After six weeks, the mother reported that Cindy was a different child – happy, co-operative and starting to make friends. Her mother even heard her humming the Theraplay songs to herself while doing her chores. Of course there is still work to be done, but surely this combination of CBT and Theraplay offers the best of both worlds!
Booth, Phyllis, Jernberg, A. (2010) Theraplay: Helping parents and children build better relationships through attachment-based play. 3rd ed. John Wiley & Sons.
O’Kelly, Monica (2010) CBT in Action. A Practitioner’s Toolkit, CBT Australia