When I lecture on CBT for children and adolescents, I am often asked, "How can I help my younger clients to really understand the cognitive model? Isn't it too abstract?" Helping clients to understand the connection between thoughts, feelings and behavior is a key, initial step in teaching them how to examine and modify their cognitions. It is essential, therefore, to explain the connection in client-relevant terms. I have found a particular simple story that resonates well with clinicians and their clients, particularly those clients for whom a more concrete, applied explanation of the model is appropriate. A version of this story, the Rollercoaster Story", was first published in Cognitive Therapy for Adolescents in School Settings (Creed, Reisweber and Beck, 2011). It is just one example of how the cognitive model can be explained through a story. The story itself can and should be modified as needed.

The "Rollercoaster Story" is typically presented early on in treatment, usually during the first or second session, to illustrate the cognitive model and how it will be used in therapy. Some therapists prefer to draw pictures on paper or a white board while telling the story to further engage the client. Others may create an illustration that can be photocopied for the client. It is important for therapists to find a comfortable way to present this story in their own individual style, using language appropriate to the client.

Thus, the story that follows should be considered an example rather than a script.

The Rollercoaster Story

"One day, two friends headed to an amusement park for some fun. In the center of the park was a huge roller coaster. When the boys saw the ride, something very strange happened. One boy, named Moe, ran to get in line to ride the roller coaster. The other boy, Joe, walked much more slowly to get in line. As they stood together, they looked something like this."

At this point, the therapist would draw a picture of the two boys. Moe should show non-verbal cues that he is very excited: a big smile, open body posture, and so on. Joe's non-verbal cues should suggest that he is quite anxious: wide-open eyes, a more grimly-set mouth, and so on. Alternatively, the therapist could point to pictures on a pre-prepared illustration or use other methods to show two boys with these two different emotions.

"Let's look at Moe. How do you think Moe is feeling?"

The emphasis in this question should be on how Moe feels, based on the nonverbal cues, rather than what he is thinking or doing. If necessary, use guided discovery questions to help the client recognize that Moe is excited and happy.

"And if you look at Joe, how do you think Joe is feeling?"

Again, emphasize how Joe feels, rather than what he is thinking or doing.

"I think you're right--Moe looks like he is feeling really (excited/good) about riding the rollercoaster, but Joe looks really (worried/nervous/unhappy). So here's the interesting thing: Some people think that situations make them feel a certain way--like the rollercoaster making Moe excited and making Joe scared. But if they're both in line for the same rollercoaster, how could it be that they feel so differently? What could be making them feel differently?"

Encourage the client to take some guesses. If necessary, use guided discovery or float ideas to help the client consider that what the boys are thinking about the rollercoaster is quite different. If necessary, ask something like, "What do you think Moe is saying to himself while he's standing in line? And what is Joe saying to himself?" We are looking for the (automatic) thoughts that each boy is having when he looks at the roller coaster. Drawing a thought bubble over each boy's head may also help clients to consider what is going through each boy's mind. The goal is for the client to consider that Moe is having positive or optimistic thoughts, and Joe is having negative or pessimistic thoughts.

"I bet you're right. Moe is probably thinking about how fun the rollercoaster will be, and Joe is probably thinking that something pretty bad will happen. So I wonder . . . is it possible that the roller coaster is not making the boys feel this way? Is it possible that something else might be doing it?"

Use other questions as needed to help the client draw the conclusion that the boys' feelings are related to their different thoughts about the rollercoaster ride.

"So now let's think about something else. What could Moe whisper in Joe's ear to help Joe feel a little bit better about riding the roller coaster?"

Here, the therapist is looking for a thought that could help Joe cope with his worry and ride (not avoid) the rollercoaster. Examples include, "I'll sit next to you so you feel better," "I know you can handle it!" or "Think of how proud you'll feel afterward!"

"I think you're right. If Moe tells Joe he'll sit with him, and then Joe focuses on feeling proud afterward, Joe will probably feel better about riding the rollercoaster. He may still feel a little nervous, but changing his thoughts may help him be brave enough to give it a try."

"That's a lot like the kind of work we'll be doing together. We're going to help you learn to catch what you're saying to yourself, and then whisper something in your own ear to help you feel (less angry, more brave, less sad, more relaxed, etc.) We'll figure out what you are thinking in different situations and how those thoughts lead to feelings and actions. Then we'll figure out what you can tell yourself, or whisper in your own ear, to help you feel better and act differently. How does that sound?"

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The rollercoaster story is just one technique therapists can use to explain the cognitive model concretely. Further, the rollercoaster in the story could be replaced by something else that two people may think about differently. Using examples that are relevant to things the client really likes (or dislikes) can make the story more fun, engaging, and relatable. For example, a similar story could be told about two children who see a mouse sitting on their front steps. One child may feel anxious or uncomfortable about the mouse, and the other may be excited about trying to pet the little furry creature.

Using examples that are in line with the client's presenting problem may sometimes be helpful (e.g., using an anger example for a client who often experiences anger). However, an example that is too similar to the presenting problem can be distracting or off-putting. Having clients tell a new "Rollercoaster Story" with something besides a roller coaster is also a helpful way to check the client's understanding of the concepts behind the story. Likewise, asking the client to generate thoughts that the happy child could whisper in the other child's ear is a useful way to check their comprehension. Children and adolescents often respond well to these kinds of stories and the sense of amusement-an important component of this technique-that accompanies them. Again, therapists must use their clinical judgment and knowledge of the individual client to find a method of explaining the model that works well for them and their clients.

Reference:

Creed, T.A., Reisweber, J., & Beck, A.T. (2011). Cognitive Therapy for Adolescents in School Settings. Guilford Press: New York.