Session 10 CBT and Therapeutic Storytelling
Therapeutic Storytelling in Conjunction with Cognitive Behavioural Therapy with a 16-Year-Old Male This is an example of a case in which therapeutic storytelling is integrated with cognitive therapy with a youth who is experiencing symptoms of high anxiety, obsessive-compulsive disorder, and panic attacks. It would appear that some or all of these symptoms may have been a result of prior drug and alcohol abuse. I have used this same approach with depression, phobic reactions, and psychosomatic complaints, obtaining similar results, however the length of treatment varies with each case. When I use therapeutic storytelling with teenagers, I usually discuss with them the fact that I use stories in conjunction with insight-oriented therapeutic interventions like cognitive restructuring. I follow with a brief explanation of cognitive restructuring. Then I briefly instruct them on right and left brain hemispheric functions and explain that storytelling is a right brain task and that cognitive restructuring is a left brain activity. After some discussion, most adolescents begin to appreciate the importance of both forms of therapy. I have found that when these two modes of therapy are used in conjunction with each other, that one complements the other. This type of therapeutic storytelling program consists of two 90-minute appointments and four 60-minute appointments. Each appointment includes an interview with the youth and a storytelling session. The 90-minute appointments are used to
give me extra time to teach cognitive and behavioural strategies. The interviews are used for teaching as well as discussing any significant regression or progression in managing feelings, thoughts, and or behaviours that may have occurred between therapy sessions.
Family Interview I had met with Steven and his parents six months prior when they were having behaviour management problems with him. They only attended three sessions and stopped because Steven refused to come any more since he felt it was not helping him. I met with both parents for this interview and learned that Steven’s oppositional and defiant behaviour had continued and that they had learned from him that he had a history of drug and alcohol abuse. Steven was the oldest of three siblings and all three children resided with their biological parents. The parents reported that Steven was having obsessive thoughts; these centered on the fear that if he vomited he would get sick and would end up in the hospital where he would eventually die. He was fearful of eating certain foods, being with people who were ill, and of being in situations or conversations that implied or mentioned sickness or vomiting. This fear became so intrusive that for three days he lay on the couch for fear that he would be sick if he stood or sat up for very long. The parents took him immediately to their family doctor who concluded that Steven was in good physical health and that perhaps a mental health professional could help to relieve the problem.
SESSION ONE Counselling Session I met with Steven two days after his episode (the three days on the couch) and he reported that he could not keep the fear of vomiting away from his consciousness for more than an hour at a time. He also mentioned that he was worried that perhaps his drug abuse had caused him to “go crazy.” He was embarrassed by his preoccupation with “puking” saying, “It’s so stupid to think this way, but I can’t stop!” The main motivator for Steven, it turned out as the interview progressed, was that the family was going on a holiday, and he was not sure if he could cope with it. The trip included travelling by car for two days. He was fearful of getting “carsick” and was wrestling with the decision to go or to stay with his grandparents. He was not sleeping well because of his anxiety around the decision and was not eating well because he was afraid he would vomit. Another complication was the fact it was flu season, and he was fearful of contracting it. I
wanted to encourage Steven to go on the trip with his family in order for him to have some success with this form of therapy as well as to encourage him to stop his compulsion from controlling his life. We had a discussion concerning the trip, and he explained the precautions that he and his mother had thought of to allow him to go on the trip. They decided that frequent stops, sitting in the back of the van where there was a bed, and rolling the windows down while travelling so he could have constant fresh air, would
make it possible for him to go. I assured him that today’s session would focus on providing him with strategies to assist him with his decision and in a secondary way provide him with some useful thoughts that might assist him on the family trip should he choose to go.
Storytelling Session The first story I told is entitled “Up in a Tree” (Burns, 1982, 2013). The story is about a child who, because of his adventuresome spirit, climbs a tree higher than he has ever climbed and panics. Now he is stuck in the tree and unable to move and is forced to ask for help from two elderly adults. They talk with him and eventually help him to lower his anxiety and climb down again. This story had some obvious messages for Steven. The boy’s adventuresome spirit symbolized Steven’s drug and alcohol abuse. He was clearly stuck and frightened, as was the boy. He needed to listen to someone older and wiser to help him help himself but not someone to do it for him. The second story I told was “Hunter and Son” (Burns, 2012). This is a tale of conflict between father and son, which ends with son leaving home. Steven and his father had been involved in an ongoing conflict for the past two years, and I wanted him to consider this as a possible source of his anxiety. In addition, I wanted to recognize, in a metaphorical way, his need to follow his path and not that of his father’s. And finally I wanted to communicate that this conflict with dad and with his thoughts would require making some very
difficult decisions about how he was living. The story also has a wide variety of messages that appeal to, and are important to, male adolescents, which made this story more useful and meaningful for him. The final story I told was entitled “The Norseman” (Burns, 1982, 2013). This is a story of a young man who has to leave his home and family and go off on a dangerous and adventuresome journey. The Norseman becomes depressed but in time learns to change his internal images and ways of thinking so that he is no longer despondent. There was one line in the story that I emphasized, “He realized that he could think about and remember whomever he wanted to”. This story was useful to Steven because the dangerous and adventuresome journey could symbolize both his family vacation and his therapy. The Norseman’s depression would parallel his obsessive-compulsive state. The fact that the Norseman learned to alter his thoughts so that they would not trouble him suggested to him that he could learn to do the same. I ended the session with an exercise to slowly bring Steven’s thoughts back to the external world but decided not to have him explain or draw any of his experiences with the story. The time was a factor because we had been working for 90 minutes, and I felt that he had had enough. I also wanted to end without placing any emphasis on any one of the images and symbols contained in the trilogy but rather to have them all considered of equal merit. Steven had relaxed quite quickly and was deeply relaxed for all three stories, and so I felt no need to explore the stories any further.
SESSION TWO Counselling Session This meeting was two weeks after our last session as Steven had decided to go on the family vacation. He stated that he had decided to go on the trip after talking with his parents following his first session. He felt that he was able to contain his fears for the most part throughout the trip and had enjoyed the time away with his family. He had thought about vomiting as much as he had prior to his first session but stated that it was “not as strong in me.” He also became aware that his obsessive feelings were more likely to be a problem when he was away from his family or home. He said he became aware of this when he returned to school after his vacation and found that his fears returned with the same frequency and intensity as before.
Storytelling Session I began our second session in much the same way as the first one and told Steven the story of “Vasalisa” (Burns, 2012). This is a story of a young girl who accomplishes the impossible with the help of her courage and her inner wisdom. I wanted to communicate several messages to Steven with this story, first and most importantly was the message that he is capable of doing the impossible (thinking normally again). I also wanted to let him know that he was not alone and that he would benefit from some outside help. I wanted him to understand that life experiences can sometimes not make sense (his obsession), can seem magical or transformative (overcoming the obsession) but can be accomplished by simple everyday events (lying down
and relaxing the body). I wanted to communicate that he has an inner voice or guide (unconscious mind) that can help him decide what is best, but it will not be easy (coming to every session on time and allowing himself to be vulnerable). I had him slowly return his thoughts back to the events in the room and asked him if he would like to draw the scene in the story that he remembered the most clearly. He chose to discuss his favourite scene with me rather than draw it. He chose the part in the story where Vasalisa brought the fire home to warm and light up the interior and the fact that the stepmother and stepsisters were destroyed. This scene is the end of the hero’s journey, where she returns home having accomplished her task. Perhaps Steven chose this scene because he is anxious to complete this process and return home in triumph. I asked him to come back for another session in two weeks and suggested to him that in the interim he could use his inner voice to assure himself that now everything was going to be all right.
SESSION THREE Counselling Session Steven reported that he had had a difficult time between the second and third sessions. He contracted the flu and was at home sick for three days; he stated that he was in a panic at school when he first came down with the flu and for days after he returned to school. He said he was all right when he was at home feeling sick and that most of his anxiety was occurring at school. He said he was worried that, “If I throw up, I’ll freak somebody out, and they will be disgusted with me.” He described his stomach “taking flips” and being afraid of the panic. We discussed and reviewed several intervention strategies that he could use to relieve the anxiety. Some strategies he had been using such as positive self-talk and limiting his time at school. Others, that he had identified previously, but ones that he had not been using, such as going for a walk, drawing in his art book, or talking with a friend, were explored and encouraged.
Storytelling Session I began the third session as I had the previous sessions, with Steven lying on the couch, the lights dimmed, and the same styles and content of relaxation exercises as before. I told Steven the story of “Conn Eda” (Burns, 2012). Conn Eda is a young man who is banished from his home and sets out to do the
impossible. With the help of a few mystical characters, he is able to return home and reclaim his rightful place. The overall message to Steven was, “Once it was good, and then a crisis hit, but with courage and determination and a little help from others, peace will return.” Steven needed to reclaim his home (his thoughts). In the story there are several references to “spells” being placed on different characters. Steven, in a metaphorical sense, had a spell placed on him, and the story provided ways for him to consider how to undo the spell. Conn Eda’s spell is his banishment, and his absence perpetuates the spell that has been cast upon the land. He seeks out the advice of a holy man who gives him a guide and a charm (precious stone) to help him to regain his kingdom. Steven’s entrance into a therapeutic relationship with me is a direct parallel to seeking the holy man. Conn Eda courageously ventures out into the world and risks his safety many times before he is able to acquire the prize that sets him free. Steven was having difficulty venturing out in to the world (school), and he had to risk his emotional safety (increased anxiety) and his social safety (away from home) in order to win the prizes (lower anxiety, increased confidence, and further developed social skills) that would set him free. Steven was deeply relaxed through most of the story and took a lot of time refocusing back to the room. He chose the scene in the story where Conn Eda asks the “bird with the human head” for help. He said he would like to talk to that bird and find out what his future was going to be (the bird knew all things past and present and could see into the future). I asked him to look and tell me what he saw, and Steven replied that he saw himself in college studying to be an architect. I asked him to return in one week and we would continue with the process.
SESSION FOUR Counselling Session Steven reported that he was continuing to have problems with his obsessive thoughts of vomiting and went on to say that he had been having episodes that I took to be the symptoms of panic attacks. He said that they had begun seven months ago but had been infrequent until this week when he experienced one or two episodes a day. Steven stated that he did not mention them before because he was “too embarrassed.� His mother was out of town this week, and he felt that this was what brought on his intense fears. Steven said he felt that there was no one at home who could help him. He felt that the relaxation techniques that he had learned over his first three sessions had helped him to reduce his anxiety, and he also reported success with using artwork to distract himself and to express some of his fears.
I invited his parents to sit in on the final 10 minutes of our interview in order to discuss the possibility of medication to assist Steven with his anxiety. Steven felt that he would like to continue with the counselling until the six sessions were completed before he tried using medication. Steven made the statement that he thought it was his use of drugs that had caused this problem, and
he wanted to use them only as a last resort. His parents were in agreement as long as his condition did not worsen. Although Steven’s situation appeared to be getting worse instead of better, I was not concerned. The therapeutic relationship was developing, and he was reporting his symptoms more honestly. He was relaxing more deeply with each session and appeared to have confidence in the process.
Storytelling Session I chose to tell Steven the tale of the “Firebird,” which is not in the compilation from Into the Dark Forest. I had originally planned to tell him the story of “Iron John” (Burns, 2012), but due to the deterioration in his condition, I decided to tell him this story instead. “Firebird” is a Russian tale that relates the story of a young man who possesses a wise horse to guide him. He does not take the horse’s advice when he is tempted and as a result experiences much suffering. He is forced to accomplish impossible tasks in order to save his life. The suffering and the challenges to free himself from the king’s demands become increasingly more difficult, and his situation worsens with each attempt to remedy it. His one saving grace is his “horse of power” that continues to support him and assist him in dealing with his challenges.
I felt that the situation of the young man in the story was very close to Steven’s situation. The horse of power symbolizes Steven’s own wisdom as well as the wisdom of the therapist and the therapeutic intervention. The young man in the story does not listen to his horse and picks up the feather of the firebird. The feather, which represents in the story that which is uncommon and full of mystery, symbolizes for Steven his drug and alcohol abuse. The course of the young man’s predicament, which gets worse instead of better, symbolizes the present course of therapy. The young man however remains faithful to the counsel of the horse of power and in time accomplishes his impossible task and is rewarded. Steven said he related most to the scene in the story where the young man and the horse capture the firebird. He said he liked the way that they lured the bird and finally captured it. I asked Steven to draw that scene and contemplate it for the next two weeks.
SESSION FIVE Counselling Session Steven reported a significant change in his symptoms over the two weeks between sessions. He said that the panic attack symptoms had not reoccurred and that his feelings of anxiety had lessened considerably. He was still somewhat anxious about vomiting, but he found that he was not as preoccupied with it as before. We talked briefly about continuing to allow the treatment to evolve and the fact that it takes about 10-12 weeks to assimilate all that he has learned as a result of his therapy.
Storytelling Session At this point, I decided to tell Steven the story of “Iron John� (Burns, 2012) which is a tale of masculine development. I felt that this story would symbolize his present situation as well as give him direction for the future. It has been my experience that once the therapeutic intervention starts to cause changes in the child, he is well on his way to recovery. This story tells of a young boy who is introduced to a wild man, or symbolically the wild untamed aspects of his personality; I believe all adolescent males have a strong attraction to this type of masculine energy. But, since they do not have a way to connect with it, they experiment in drugs, alcohol, and violence to try to get in touch with this powerful force within themselves. The story describes a number of experiences that the young boy has which challenge his abilities. Once he
befriends the wild man, he is able to meet these challenges with the wild man’s help and eventually evolve into mature manhood. Steven related to the scene where the princess in the story discovers that the gardener’s boy is more than he appears to be. I suspected that Steven was coming to the same realization about himself. I suggested that we not meet for some time, to allow the assimilation process to complete itself, but that he could call and set up an earlier appointment if his situation worsened. We decided on a period of four weeks before our next session and discussed the fact that it was our last contracted session and we would try to stay true to our agreement.
SESSION SIX Counselling Session Steven reported that his symptoms slowly abated and he had not had any symptoms of panic or obsessive thoughts of vomiting for the past two weeks. He said that he was feeling emotionally stronger at school and reported an increase in his test scores, which indicated that he would likely pass all his subjects that semester.
Storytelling Session The final story I told Steven was Meade’s telling of the German tale, “The Water of Life” (Meade, 1993). This is a story of the “little fool,” the person or aspect of the personality that is not taken seriously, is underrated, or is devalued. The story also addresses the notion that a young person must prepare before he sets out on a journey or a wandering, for example, off to high school, off to college, or off to a mature and responsible attitude. The youngest son, with his honesty and ability to take direction, is able to save his father’s life. He has to deal with two manipulative and deceitful brothers who try to control and destroy him, but he is triumphant in the end. Steven’s image of himself prior to beginning his therapy was much like the youngest son’s. Steven needed to take part in the journey and stop finding ways to stay at home and avoid school
life. He had two difficult issues to overcome in the guise of drugs and alcohol that could control and possibly destroy him. The message of the story to Steven was “We know how it has been for you. You have a difficult task ahead of you. There is help for you if you need it. You have what is required to triumph over your adversary. You will succeed.” I decided not to discuss this final story with Steven, and instead we talked about his success and the termination of his therapy. He had overcome a major psychiatric condition, obsessive compulsive behaviour with psychosomatic overtones. He had dealt with his paranoia, acute anxiety, and depression, all in a matter of 12 weeks. I assured him that this was nothing short of miraculous and he should be extremely proud of his accomplishments. We agreed that should any symptoms return that he felt he needed help with, he would call and make an appointment.
Follow-Up After three years Steven’s parents reported that he is doing very well and has not had a reoccurrence of his previous symptoms.
Epilogue Cognitive behavioural therapy and therapeutic storytelling can be a very powerful combination for adolescents and young adults. This combination uses implicit and explicit messages to achieve its goals. The process of right brain and left brain communication and validation allows participants to use all of their resources to assimilate the change process. Steven clearly needed to talk about his problems but also needed to deal with a number of feelings that were troubling him. The combination of these two treatment modalities allowed him to accomplish this somewhat impossible task.