Before beginning the main topic for this column I would like to introduce the concept of the Child Clinician’s Corner. From 2002 through 2005 I authored a serial column on webpage authoring and usability for the IP. I ended that column when I ran out of things to say (all of these columns are available for download on both the Division 42 website and my website). I am now returning, with the kind permission of the Editor, to offer a serial column on practice issues in child clinical psychology. In the past 10 years I have given over 120 continuing education workshops on child related topics around the country. Because of my interactions with colleagues at these trainings it seems that there could be value in sharing strategies for child clinical work that are practical, consistent with an evidence-based approach and possible to review in a brief column. In this first edition I would like to review a strategy to use when doing interventions with juvenile psychiatric disorders that are either persistent or have a high relapse rate. This strategy is called externalizing the problem.

Examples of this strategy can be found throughout the clinical literature. For instance, Neil Jacobson used to recommend this strategy in couples counseling when relationship problems could not be overcome via behavioral interventions: he referred to it as “turning the problem into an it.” Likewise, when I worked on an NIH funded project at the George Washington Medical School, we would encourage families, who had a member who was receiving dialysis treatment, to set a place at the table for the kidney disease. Examples can also be found in the child clinical literature (e.g., Fristad’s and Goldberg-Arnold’s psychoeducational manual for bipolar disorder, March’s and Mulle’s intervention manual for OCD, etc.). Though this strategy has been around for a while, I find that many child clinicians have not been exposed to it. As I find it offers a rich clinical yield, I thought it a good introductory topic for this column. Here I will focus on its application when doing CBT with a depressed child, though I will review other potential applications at the end.

A key concept imbued in this strategy is that when a child is suffering from depression she is under attack. Asthma attacks the airways. Leukemia attacks the blood cells. Depression attacks the brain. To quote Stephen King: “Monsters are real, and ghosts are real too. They live inside us, and sometimes, they win.”
First, I ask a child to try to think of a name for her depression. I will give her examples of what other children have named their depression and why. Then, I ask her to remember a time when she was especially sad, and to recall the sensations of that moment. I ask her to imagine that she was under attack and to come up with a name for the attacker (sometimes this becomes a homework assignment). One 10-year old boy called his depression “the body taker” because it would take over his body when it attacked him. A 16-year old teen described his depression as “the fog” because it would start out at his feet and rise slowly until all he could see or feel was it, while a 13 year old girl described her depression as “the veil” because everything she viewed in her life was seen through it. “The undertaker”, “the blob”, “the beast”, “the vampire”, “Betsy” (after a decreased haranguing aunt) and “the bitch” are other examples. I also like asking younger clients, and teens with an artistic leaning, to create drawings of their attacker. Once the depression is named, there is a great deal of clinical yield that can be garnered.

Once named, I try to limit my use of the word “depression”, and use the name of the attacker instead. Early on I’ll draw a vertical line down a sheet of paper and ask a child to list, on the left side, his personality characteristics. On the right side we then list the characteristics of the perpetrator. We then talk about what we both think and feel about this creature. My clients and I will often agree that we “hate” the attacker and despise how it ravages her when it is dominant.

I suggest to a child that much of the attacker’s power has been drawn from the fact that it wasn’t recognized and attacked in the dark. I further suggest that both he, and those around him, understandably, but mistakenly, probably thought the attacker’s personality characteristics were his; I then ask for either a confirmation or a rejection of that speculation (they usually say that is true and enjoy providing examples). I further suggest that we, however, are able to throw light on this attacker, recognize how it attacks, and develop effective weapons for defeating it.

I suggest to a child that the attacker does not have 1000 ways it attacks, but has a rather limited range. Moreover, I suggest that I can teach her to use an array of powerful weapons to defeat each type of attack. I will review two examples here.

When teaching behavioral activation (i.e., doing pleasurable activities), I’ll suggest to a given child that I’d like to make a guess that “the beast” often attacks him by whispering things like “Don’t do that thing because you don’t feel like it. Just rest and take it easy.” I ask him if he has ever heard that message in his head after others have invited him to do things that were suppose to be fun. Most of the time the child can readily come up with several examples (when they can’t the parents usually can). I then ask him to describe how he felt resting, both during and after; again, he will usually describe how this made him feel no better and often worse. I suggest that this is “the beasts” way of trying to get him into a depression bath. I propose that while a regular bath can be refreshing, and exited easily, that a depression bath usually sucks a person down into the sewer and can be hard to get out of. We then talk about him trying out the weapon of doing pleasurable activities–as is reviewed in the Taking Action or the Steady treatment manuals–in order to see how good of a job that does in counterattacking the invitation to take a depression bath. (I also have a cartoon I use of a bird talking to a man. The bird states, “I don’t sing because I’m happy. I’m happy because I sing.” If you’d like a copy just email me.)

When teaching thought testing I suggest that “the veil” probably tries to convince her of things that are not true and are very hurtful. I’ll ask for examples of thoughts she is having that hurt a lot. I suggest that it can be hard to distinguish what is a “Janet” thought (a true thought) from a “Veil” thought (a painful lie). However, I suggest that it is very easy to test a thought to see which type it is. We write down the thought at the top of the paper and then draw a vertical line down the middle of the paper. I then ask for all facts that suggest that the thought is true (I find the detective metaphor used in the Taking Action program to be helpful here). This often surprises children. Depressed children are used to having adults try to argue them out of their depressive thinking, which, as you know, has the paradoxical effect leaving the child arguing for the depressive thought, much to the supreme frustration of well intended adults. Once the child has indicated she has no more instances of this type of fact, we then review the facts suggesting that the thought is not true. If more evidence exists on the right side, we conclude that it is a “veil” thought and discuss what the child can do to weaken it (e.g., do a pleasurable activity, relax their muscles and do diaphragmatic breathing, use a coping thought, distract themselves with another activity or thought, etc.). If there is more evidence on the left side (much less common), we “think of it as a problem to be solved” and loop into the problem solving technique.

Parents eat this method up. Externalizing the problem allows them to unleash their often repressed and suppressed negative thoughts and feelings about the disease. How many parents want to hate their baby? However, it is very easy to hate “the beast”. And, as the old psychoanalytic saw goes, negative feelings that are owned, discussed and understood are much less likely to get acted out. Moreover, parents can be invited to conceptualize their coaching and reinforcement of CBT strategies with their child (post therapist coaching and reinforcement with them) in this same context: “uh oh, it seems like ‘drops’ is starting to attack you. What can you do to keep it from kicking your butt?” I’ve also arranged for token economy systems to deliver points to a child if he demonstrates a reasonable effort to use his CBT weapons to fight “the bully”.

This technique is also easily adopted in cases when children are receiving psychopharmacotherapy. If the child is old enough, we’ll talk about how serotonin is another weapon that can be used to weaken “the blob.” Or, we simply discuss how the medication helps him to be better able to pick up and wield his CBT weapons.

In the relapse prevention phase of the work we review the methods that the child and the parents have used to conquer “the fog”. However, I also caution–in instances when either the research or a given child’s situation suggests that there is a risk of relapse– that while “the trap” has been beaten back deep into the woods, it is probably laying in wait and looking for a chance to attack again. I suggest, however, that if the child and the parents can be on watch for the signs of a new attack (which we review), that it is highly likely that the same CBT weapons will be successful once again. I suggest that “the undertaker” is most likely to attempt another attack during times of change and stress (including positive stress) or when the child’s body is depleted (i.e., from poor diet, lack of sleep or lack of exercise). Of course, I also offer my help at any time should they wish to come back in for more coaching and I usually schedule a booster session for six months out.

I’ve focused on using CBT in the treatment of juvenile depression. But externalizing the problem can be woven into just about any treatment, across the lifespan, for disorders that are persistent (e.g., addiction lies by telling you you’ll never really relax again and have a good time without it, anxiety lies by telling you to avoid that thing because it’s dangerous, etc.).

Let me offer a few closing comments. First, the ordering information for any treatment manual I’ve referenced can be found by entering its name in the search engine found on my website. Second, I am available for email dialogue for any who would like to discuss these issues further. Third, and while I have a number of future columns already in mind (e.g., the value of damage control treatment contracts, an individual interview method during the assessment phase, techniques for establishing adherence and coping with resistance, etc.), I am very interested in receiving suggestions for future editions of this column. For now, thanks for reading and I wish you good fortune as you help children to battle their demons.

David Palmiter is a practicing psychologist, a psychology professor and director of the Psychological Services Center at Marywood University and a member of the Board of Directors of the Pennsylvania Psychological Association. His webpage is www.kidtherapist.com. His email address is palmiter@marywood.edu.